Google
This is a digital copy of a book that was preserved for generations on library shelves before it was carefully scanned by Google as part of a project
to make the world's books discoverable online.
It has survived long enough for the copyright to expire and the book to enter the public domain. A public domain book is one that was never subject
to copyright or whose legal copyright term has expired. Whether a book is in the public domain may vary country to country. Public domain books
are our gateways to the past, representing a wealth of history, culture and knowledge that's often difficult to discover.
Marks, notations and other maiginalia present in the original volume will appear in this file - a reminder of this book's long journey from the
publisher to a library and finally to you.
Usage guidelines
Google is proud to partner with libraries to digitize public domain materials and make them widely accessible. Public domain books belong to the
public and we are merely their custodians. Nevertheless, this work is expensive, so in order to keep providing tliis resource, we liave taken steps to
prevent abuse by commercial parties, including placing technical restrictions on automated querying.
We also ask that you:
+ Make non-commercial use of the files We designed Google Book Search for use by individuals, and we request that you use these files for
personal, non-commercial purposes.
+ Refrain fivm automated querying Do not send automated queries of any sort to Google's system: If you are conducting research on machine
translation, optical character recognition or other areas where access to a large amount of text is helpful, please contact us. We encourage the
use of public domain materials for these purposes and may be able to help.
+ Maintain attributionTht GoogXt "watermark" you see on each file is essential for in forming people about this project and helping them find
additional materials through Google Book Search. Please do not remove it.
+ Keep it legal Whatever your use, remember that you are responsible for ensuring that what you are doing is legal. Do not assume that just
because we believe a book is in the public domain for users in the United States, that the work is also in the public domain for users in other
countries. Whether a book is still in copyright varies from country to country, and we can't offer guidance on whether any specific use of
any specific book is allowed. Please do not assume that a book's appearance in Google Book Search means it can be used in any manner
anywhere in the world. Copyright infringement liabili^ can be quite severe.
About Google Book Search
Google's mission is to organize the world's information and to make it universally accessible and useful. Google Book Search helps readers
discover the world's books while helping authors and publishers reach new audiences. You can search through the full text of this book on the web
at|http: //books .google .com/I
0(^
* -
jL^i^ait@
LANE MEDICAL LIBRARY
STANFORD UNIVERSITY
MEDICAL CENTER
STANFORD, CALIF. 94305
/
SURGICAL PATHOLOGY.
LECTURES
ON
SURGICAL PATHOLOGY,
DBLIYERBD AT THB
ROYAL COLLEGE OF SURGEONS OF ENGLAND.
• , - . --
* * M • • •
4 •• »• ••
« * I
JAMES PAGET, F.R.S.,
KTBOWII BZTKAOKDDrAST TO HXR KAJISTT THS QUKBIT ; 8UB0K09 IN ORDINARY TO HIS ROTAL HI0HMI88 TBI
PRINOI OP WALE0; BUROION TO 8T. BARTHOLOMEW'S AND CHRIST'S B08FITAL8.
RBVISBD AND EDITBD BY
WILLIAM TURNER, M.B. Lond., F.R.C.S.B., F.R.S.B.,
SBVIOR DIM0N8TRAT0R OF ANATOMY IN THS UNIYZRSITY OP IDINBUROH.
Wxi %mfw^n (BMoiL*
PHILADELPHIA:
LINDSAY & BLAKISTON.
1865.
• • !•• ••
• • • • -«
1 • • • • •
• • • • • •
• •
• •
• • •
TAXTON PRESS OF SHERMAN A CO.
I - • - •
TO
P. M. LATHAM, M.D., ahd GEORGE BURROWS, M.D.,
WH08C SKILL HAS BUN PIBMITTED TO PRV8BRVB MT LIFB,
WH08B FRIENDSHIP ADDS LAROELT TO MT HAPPINESS,
AND TO WHOSE TEACHING
I SHALL ATTRIBUTE MUCH OF WHATEVKR GOOD MT WORK MAT DO,
H AtAicnU tUi Wtlunt,
WITH GRATITUDE, AFFECTION, AND RESPECT.
PREFACE
TO
THIS EDITION.
When the time came for preparing a Second Edition of these Lec-
tures, I was anxious that they should he revised with all the light of the
knowledge of Pathology acquired since their publication. But, although
I had collected some materials for this purpose, yet a thorough revision
of the whole subject was a task for which I felt unfit. For in the pas-
sage of nine years, I had been carried into the active practice of my
profession ; and, at their end, had no sufficient time for either studying
or thinking carefully about the many facts and probabilities, and
guesses at truth which had been added to Pathology. I was, therefore,
glad to be able to commit the work of revision to my friend and former
pupil, Mb. Turnbr, whom I know to be not only very conversant with
the progress of medical science, but able to test others' observations by
his own. It is not for me to say how well he has done the work, for I
have so worked with him as to be equally with him responsible.
Jambs Paget.
PREFACE
TO THE
SECOND VOLUME OF THE FIRST EDITION.
The Lectures in this yolume, and especially those on Cancers, are
enlarged far beyond their original extent, by the addition of cases,
statistical tables, and various statements which may be worth reading,
but of which the recital could not be made agreeable to an audience.
In making these additions, I have endeavored to adduce sufficient evi-
dence for the general conclusions I have drawn, without encumbering
the book with such a mass of details as would be repulsive to the ma-
jority of readers. I can hardly imagine, that a full relation of so many
cases as I have referred to would be acceptable to any besides those
who are engaged in the especial study of the subjects of the Lectures.
To all who are so occupied, I will very gladly give whatever further
information my manuscript records of cases can supply.
It is an unavoidable defect of lectures on general pathology, that
they cannot be conveniently used in the study of the diseases of par-
ticular organs. I have endeavored to amend this, in some measure, by
a full index, referring, under the title of each organ, to the descrip-
tions of the tumors of which it is most apt to be the seat.
PREFACE
TO
THE FIRST EDITION.
Nearly all the Lectures in these volumes were delivered at the
Royal College of Surgeons, during the six years, from 1847 to 1852,
in which I held the office of Professor of Anatomy and Surgery to the
College. So many listened favorably to them, that I venture to hope
I am not wrong in thus enabling many more to read them. But, in
offering them to this larger class, some explanation of their scope and
plan seems necessary.
The circumstances of my election to the Professorship indicated the
Pathological Museum of the College as the appropriate subject of the
Lectures ; and the first portion of the Museum, devoted to the illustra-
tion of General Pathology, seemed to offer the best plan by which the
knowledge acquired in a long study of the whole collection might be
communicated.
The modes were many in which such a subject might be treated in
lectures ; but, as circumstances had decided the subject, it seemed well
to let them determine, also, the method, and to adopt that which was
most natural to one engaged in the simultaneous practice of surgery
and teaching of physiology. Thus guided, I designed to give lectures
which might illustrate the general pathology of the principal surgical
diseases, in conformity with the larger and more exact doctrines of
Xii PREFACE TO THE FIRST EDITION.
physiology ; and the plan seemed the more reasonable, because it was
in accordance with the constant design of the great founder of the
Museum.
The Museum limited, while it indicated, the subjects of the Lectures.
They were, therefore, not constructed to form a system of surgical pa-
thology : several subjects, which might fill considerable places in such
a system, were scarcely alluded to in them ; and, although I have added
some Lectures, which could not be conveniently included in any of the
courses, yet I have not gone beyond the range of such pathology as a
Museum may illustrate.
The wood-engravings are, for the most part, copied from the same
specimens and drawings as were the diagrams used in the Lectures ;
and I wish them to be regarded as intended for only the same purpose
as such diagrams may serve ; viz., that of assisting the more difficult
parts of the descriptions of the objects to which they refer.
I have endeavored to make the Lectures less incomplete, and more
correct, by the aid of numerous facts ascertained since they were de-
livered, and have added to them many things which time, or their in-
aptness for oral delivery, obliged me to omit. Among these are the
references to specimens and illustrations ; as well as to numerous au-
thors who could not, in speaking, be conveniently quoted, but whom I
am now glad to acknowledge as instructors. And I will here offer my
thanks to some, to whom my debts are more than would be expressed,
even by referring to all the occasions on which their works have aided
me in the composition of the Lectures. Such acknowledgments are
due, especially, to Mr. Lawrence, Mr. Stanley, Professor Owen, and Dr.
Carpenter, from whom, during many years of valued friendship, I have
derived, at every interview, either knowledge, or guidance in observing
and in thinking. I am deeply obliged, also, to all my colleagues on the
staff of St. Bartholomew's, from whom the constant help that I receive
adds daily to the debt of gratitude incurred during my pupilage. And
there are many friends, besides, to whom it is my happiness to be in-
debted for knowledge used in these Lectures, and whom I thank col-
PREFACE TO THE FIRST EDITION. Xlll
lectively, not because I owe them little, but because I cannot name
them all, and cannot thank some without appearing ungrateful to the
rest.
I desire, in conclusion, to express my acknowledgments to the Mem-
bers of the Council of the College, both for the repeated honor they
conferred on me by so often electing me to the Professorship, and for
the kindness with which many of them devoted their valuable time to
attendance at the Lectures. The encouragement they thus afforded me
makes me hope, that the labor with which I strive to justify their choice,
may have some success in the promotion of scientific surgery.
TITLES OF THE LECTURES.
PAOB
1. Nutrition — its Nature, Purpose, and Conditions, ... 26
2. The Conditions Neoessart to Healthy Nutrition, . 38
3. The Formative Process — Growth, 69
4. Htpertropht, 70
6. Atrophy — ^Degeneration, 81
6. Atrophy, 96
7. General Considerations on the Repair and Reproduction
op Injured and Lost Parts, 119
8. The Materials for the Repair of Injuries, .... 132
9. The Processes of Repair of Wounds, 146
10. The Processes of Repair of Wounds, 168
11. The Repair of Fractures, 176
12. Healing of Injxtries in Various Tissues, .... 189
13. Phenomena of Inflammation, 208
14. Products of Inflammation, 227
15. Developments of Lymph, 246
16. Degeneration of Lymph, 268
17. Changes produced by Inflammation in the Tissues of the
Affected Part, 276
18. Nature and Causes of Inflammation, 293
19. Mortification, 309
20. Specific Diseases, 321
21. Classification of Tumors, 337
22. Simple or Barren Cysts, 353
23. Compound or Proufsrous Cysts, 373
24. Fatty and Fibro-cellular Tumors: Painful Subcutaneous
Tumors, 396
25. Fibrous Tumors, 422
26. Cartilaginous Tumors, 435
27. Part 1. Myeloid Tumors, 461
Part 2. Osseous Tumors, 472
XVi TITLES OF THE LECTURES.
ucnmx PAOs
28. Part 1. Glandular Tumors^ 484
Part 2. Yasoular or Ereotile Tumors, 495
29. Recurrent Tumors, 508
30. SciRRHOUB OR Hard Cancer : Part 1. Anatomy, 519
" " " Part 2. Pathology, . .541
31. Medullary Cancer : Part 1. Anatomy, 561
" " Part 2. Pathology, .581
~ 32. Epithelial Cancer : Part 1. Anatomy, 596
" " Part 2. Pathology, .... 624
33. Melanoid, H^matoid, Osteoid, Villous, Colloid, and Fibrous
Cancers, 638
34. General Pathology of Cancer : Part 1. Conditions preced-
ing THE Cancerous Growth, 668
85. The same: Part 2. Structure and Life of the Cancerous
Growth, 687
86. Tubercle, 707
LIST OF ILLUSTRATIONS.
no. FAQ I
1. Development, Growth, and Separation of an Eyelash, .... 30
^. Symmetrical Disease of a Lion's Pelvis, 35
3. Hydrocephalic Skull, 74
4. Skoll Thickened, especially at the Centres of Ossification, ... 75
5. Tibia, elongated and curved, 77
€. Fatty Degeneration of Fibres^ of the Heart: from Dr. Quain, . . .105
7-8-9. Fatty Degeneration of minute Cerebral Vessels, . . . .115
10. Repair of Crystals, 122
11. Repair of Hydra Tuba: from Sir J. G. Dalyell, 126
12. Repair of Tubularia : from the same, 127
13. Vessels and Minute Structure of an Organized Blood-clot, . . .135
14. Granulation-cells, 141
15. Nucleated Blastema, 143
16. Outgrowth of new Bloodvessels, 160
17. Channelling of new Bloodvessels, 162
18. Bloodvessels of Granulations, 162
19. A Vascular Loop among Granulation-cells, 163
20. Pus-cells, 169
21. Repair of Fracture with Ensheathing Callus, . . T .181
22-23-24. Repairs of Fractures with Intermediate Callus, . . . 183, 186
25. Repair of divided Tendons, 192
26-27. Repair of Skin, 206
28. Vessels of a Rabbit's Ear; enlarged in Inflammation: from Hunter, . 210
29. Small Bloodvessels dilated in Inflammation, 212
30-31. Vessels of the Bat's Wing; enlarged in Inflammation, . . .217
32. Corpuscles of Inflammatory Blood : from Wharton Jones, .... 223
33. Pigmental Degeneration in Mucus-cells, 244
34. Bloodvessels of Adhesions, 256
35. Lymphatics of Adhesions : from Schroeder van der Eolk, .... 257
36. Withered Lymph-corpuscles, 262
37. Fatty-degenerate Lymph-corpuscles, 263
38. Bloodvessels of an Abscess-wall, • 269
39. Humerus swollen in Inflammation, . 277
40. Separation of the Laminse of the Wall of a Femur, 278
41. Abscess in a Tibia, 280
42. Atrophy of the Head and Neck of a Femur, 280
43. Diagram of an Abscess, 282
B
XVIU LIST OP ILLUSTRATIONS.
FI«. PAOB
44. Development of Cysts in the Kidney : from Rokitansky, .... H56
46. Ovary, with many Cysts, 373
. 46. Proliferous Ovarian Cyst, 375
47. Minutely Proliferous Ovarian Cyst, 376
48. Cystic disease of the Chorion. 377
49. Mammary Cyst, with Endogenous Growth, 380
50. A similar Cyst, with Pedunculated Growths^ 381
51. Similar Cysts, clustered and filled, 381
52. Microscopic Structures of a Fibro-cellular Tumor, 407
53. Section of a Fibro-cellular Tumor, ' . . . 408
54. Diagram sections of a Uterine Outgrowth and a Uterine Tumor, . . 423
55. Minute Structure of a Uterine Fibrous Tumor, 425
56. Calcareous Deposit in a Fibrous Tumor: from Dussean, . . . .428
57. Section of a Fibrous Tumor from the Hip, 432
58. Sections of Fibrous Tumors on and within the Lower Jaw, . . . 433
59-62. Microscopic Structures of Cartilaginous Tumors, 438
63-63A. The same, 439
64-65. The same, 440
66. Cartilaginous and Medullary Tumor, 444
67. Microscopic Structures of a soft Cartilaginous Tumor, .... 447
68. Cartilaginous Tumor of the Humerus, 449
69. Cartilaginous Tumors of the Hand, 452
70. Minute Structures of mixed Cartilaginous Tumors, 455
71. Minute Structures of Myeloid Tumors, 464
72. Myeloid Tumor of the Skull, 468
73. Minute Structures of the same, 469
74. Osseous Tumor of the Face and Skull, 477
75. Minute Structures of Mammary Glandular Tumors, 488
76. The Same of Labial Tumors, 493
77. Erectile Tumor, 496
78. Bloodvessels of an Erectile Tumor, 499
79. Microscopic Structures of a Recurring Fibroid Tumor, . .511
80. The same; from another specimen, 514
HI. Microscopic Structure of a Fibro-nucleated Tumor, 518
82-83. Scirrhous Cancers of the Mammary Gland, 521, 522
84. Scirrhous Cancer-cells among the Tissues of the Skin, .... 525
85. Cancer-cells and Free Nuclei, 526
86. Withered Cancer-structures, 527
87. Degenerate Cancer-structures, 528
88. Scirrhous Cancer in a Humerus, 538
89. Scirrhous Cancer of the Rectum, 539
90-95. Minute Structures of Medullary Cancers, 569-572
96-97. Development of Cancer-stroma : from Rokitansky, .... 574
98. Epithelial Soot-cancer of the Hand, 599
99. Narrow-based Epithelial Cancer, 600
100. Deep-seated Epithelial Cancer of the Tongue, 607
101-4. Minute Structures of Epithelial Cancer, 611-613
LIST OP ILLUSTRATIONS.
XIX
no. PA«B
105. Diagram of the Formation of Laminated Capsules: from Rokitansky^ . 614
106. Melanoid Cancer, 6.^9
107. Minute Structures of the same, 640
108. Osteoid Caucer of the Femur, 648
109. Osteoid Cancer of a Lymphatic Gland, 648
1 1 0. Fibrous Tissue of an Osteoid Cancer, 649
111. Dendritic Vegetation : from Rokitansky, 656
112. Fibrous Tissue of a Colloid Cancer, 660
113. Minute Structures of Colloid Cancer: from Lebert and Rokitansky, . .661
114. Tissue of a Malignant Fibrous Tumor (Fibrous Cancer], .... 667
115. Proliferation of the Nuclei within Muscular Fibres, in Cancer of the Muscles, 689
116-117. Minute Structure of Pulmonary Tubercle: from Schroeder van der
Kolk, 709-710
LECTURES
ON
SURGICAL PATHOLOGY
LECTURE I.
NUTRITION — ITS NATURB, PURPOSE, AND CONDITIONS.
Mr. President and Gentlemen: I believe that I owe the honor of
being elected Professor of Anatomy and Surgery to the College, chiefly,
to my having been long engaged in the study of the pathological
department of the Museum, while arranging and describing it, under
the superintendence of Mr. Stanley, for the new Catalogue. I may,
therefore, fairly suppose it to be the wish of the Council that, as the
Museum is open to the examination of the members and pupils of the
College, and of men of scientific pursuit, so should be the knowledge
and the opinions which it has supplied or suggested to those who have
had occasion to study it most deeply. For, indeed, to what thus grows
out of the study of the Museum, the College has, in some measure, the
right which the proprietor has to the produce of the cultivated soil.
And when, through a long time past, your most learned Hunterian
Professor Owen has every year brought in, from every source, so large
a store of deep and wide-extending knowledge, of sagacious interpreta-
tion, and acute suggestion of the ways of Nature, I scarcely wonder
that some return should be looked for from an inferior laborer in the
field.
The subjects on which I shall first beg your favorable hearing are
those to the general illustration of which the first two series of prepara-
tions in the Pathological Museum are devoted — namely, hypertrophy
and atrophy ; the simple excess, and the simple deficiency, of nutrition
in parts. But let me previously speak of the healthy nutrition of the
tissues, and, herein especially, of the formative process which maintains
them by assimilation.
In the natural course of healthy life, the formative process manifests ,
itself in three modes, which, though they bear different names, and are
3
26 NUTRITION:
sometimes described as if they were wholly different things, yet, proba-
bly, are only three expressions of one law, three effects of the same
force operating in different conditions. The three, enumerating them
in the order of their time, are development, growth, and assimilation or
maintenance. To these succeeds degeneration, or decay, as naturally,
but probably through a deficiency in the normal formative force.
By development we mean generally the process by which a tissue or
organ is first formed ; or by which one, as yet imperfectly formed, is so
changed in shape or composition as to be fitted for a higher function,
or, finally, is advanced to the state in which it exists in the most perfect
condition of the species.
We must carefully distinguish development from mere increase ; it is
the acquiring not of greater bulk, but of new forms and structures,
which are adapted to higher conditions of existence. For example,
when in the embryo groups of primordial nucleated cells are converted
into the tissues characteristic of the ultimate structure of the part in
which the conversion is effected, there is not, necessarily, an increase in
size ; or if there be, there is something more ; there is a change of
texture, and an acquirement of power, adapted to a higher state of
existence: these constitute development. So, when from the simple
cavity and walls of the embryonic digestive system, the stomach, in-
testines, liver, pancreas, and- other organs are produced, these are
developed; there is increase, but, at the same time, something more
than mere increase.
The distinction between development and increase, or growth, is well
shown in this, — that, sometimes, even in instances in which they usually
concur, the one proceeds without the other. I might quote many
examples of this. I will choose one or two which, at the same time,
may illustrate some other striking facts.
Thus, for examples in which development was checked and growth
proceeded even beyond its normal limits, we may examine some of the
numerous malformed hearts in the Museum. One among them presents
only a single cavity; no partition has been developed between its
auricles or its ventricles ; it is, in respect of its development, like the
heart of a foetus in the second month : but though its development was
checked thus early, its growth continued, and it has more than the
average size of the hearts of children of the same age. In another,
development was arrested at a later period, when the septum of the
ventricles was incompletely formed ; the patient lived eleven years after
birth ; the development made no further progress, but the growth passed
its ordinary bounds.
And, once more, for instances in which the development was normal
and growth abnormal, you may examine such skeletons as those of
O'Byrne the giant, and of Madlle. Cracami the dwarf, in the Physio-
logical Museum. The one is eight feet high, the other only twenty
inches ; but if you compare these with the model skeletons which stand
ITS NATURE, PURPOSE, AND CONDITIONS. 27
beside them, you will not find in the one a defect, or in the other an
excess, of development ; the dwarf has not less than all the characteristic
human forms, the giant has no more; but the one is defective, the
other is excessive, in its bulk ; the growth alone has been erroneous in
both.
It is, then, in the change to a higher state of former composition that
development differs from growth, the second mode of the formative
process. In mere growth no necessary change of form or composition
occurs ; parts only increase in weight, and, usually, in size. In growth,
there is an addition of quantity, but no improvement in the quality, of
a part ; the power of the growing part increases with the growth, but
is only more of the same power ; so, in the attainment of manhood, the
heart of the boy having all its necessary parts, and all well formed,
acquires perfection by acquiring greater bulk, and, therewith, greater
power.
Lastly, in the formative process, as it is normally manifested in the
adultj f. e. in ordinary assimilation or maintenance, parts only preserve
their status. No perceptible change of size or weight ensues, no change
of form or composition ; sameness is maintained through the regular
formation of new parts in the place of those which, in the ordinary
course of life, are impaired, or die. Such are the methods of the forma-
tive process in the healthy nutrition of organs. I shall have to show in
future lectures that some of the terms just used are in a measure con-
ventional, and arbitrary ; that some instances of what we call develop-
ment, e. ^., that of cartilage into bone, are not in every sense justly so
named ; and that the sameness, which is maintained in the adult body,
fades into a gradual degeneration. But, for the present, the terms that
I have used may suflSce. It is convenient, also, to think of the three
methods of formation, as if each might be separately manifested ; yet,
probably, they are often concurrent ; the maintenance of some, or of
many, whole organs being achieved only by the constant development
and growth of new elemental structures in the place of those that are
out-worn.
Now, for the elucidation of this maintenance of parts by the constant
mutation of their elements, let me speak —
1st. Of the sources of impairment, or, if I may so say, of the wear
and tear, to which every part of the body appears to be subject.
2dly. Of the conditions necessary for the healthy state of the process
of nutrition by which the results of the wear and tear are repaired.
3dly. Of the formative process itself.
First, then, the deterioration of the- body may be traced to two
principal sources ; namely, the wearing out of parts by exercise, and
the natural deterioration or death of the elemental structures of every
part or organ, independent of the decay or death of the whole body,
after a certain period of existence.
From the first of these, the wearing-out of parts by exercise, it is
28 NUTRITION:
probable that no tissue or part enjoys immunity. For although, in all
the passive apparatus of the body — the joints, bones, ligaments, elastic
vessels, and the like — much of the beauty of their construction consists
in the means applied to diminish the effects of the friction, and the
various pressures and stretchings to which they are subject, yet, in
enduring these at all, they must be impaired, and, in the course of
years, must need renewal. In these parts, undoubtedly, the waste by
exercise is much less than that of the more active organs, such as the
muscles, and, perhaps, the nervous system. With regard to the muscles,
it is clear that chemical decomposition and consumption of their substance
attend their continued action. Such action is always followed by the
increased discharge of urea, carbonic acid, and water. The researches
of Helmholtz* show, that the muscles themselves, after long-repeated
contractions, are changed in chemical composition ; those of G. V.
Liebigt have detected and measured the formation of carbonic acid in
them during similar contractions. And further, Du Bois Reymond has
recently shown,| that the muscular juice, which, so long as the muscles
are in a state of quiescence, possesses a neutral, or faintly alkaline,
reaction, becomes, after they have been violently exercised, decidedly
acid.
We have nearly similar evidence of the impairment of the nervous
system by prolonged exertion of its power. We have, indeed, no proof
that the simple conduction of an impression through a nervous cord can
affect in any way its composition or its structure ; but the abundance of
phosphates occasionally discharged with the urine, after great mental
exertion, shows that the various acts of the mind impair the brain
through which they are manifested. To this point tend, also, the
researches of Dr. Bence Jones,§ who has shown that the excretion by
the kidneys of a large quantity of phosphatic salts is usual in acute
inflammation of the brain. And to this conclusion, that mental exercise,
whether perceptive or active, impairs the structure of the brain, we
might be led by our sensations and by our knowledge of the nature of
the Mind. For to the principle, the immaterial thing, we cannot ascribe
a weariness ; it cannot be obnoxious to waste or to decay ; mental fatigue
is only what the Mind feels of an impaired state of the brain, and the
recovery from what we call a weary mind is the restoration, not of the
Mind itself, but of the organs which it feels, which connect it with the
external world, and in which, during tranquil sleep, the reparative
nutrition goes on undisturbed.
It is, further, probable that no part of the body is exempt from the
second source of impairment ; that, namely, which consists in the natu-
ral death or deterioration of the parts (independent of the death or
♦ Mailers Archiv, 1845, p. 72. t Ibid. 1850, p. 393.
J Monat's Bericht der Akad: der Wissen: zu Berlin, 1860, p. 288.
2 Med. Chir. Trans, vol. xxx, p. 20.
ITS NATURE, PURPOSE, AND CONDITIONS. 29
decay of the whole body) after a certain period of their life. It may
be proved, partly by demonstration, and partly by analogy, that
each integral or elemental part of the body is formed for a certain
natural period of existence in the ordinary conditions of active life, at
the end of which period, if not previously destroyed by outward force
or exercise, it degenerates and is absorbed, or dies and is cast out ;
needing, in either case, to be replaced for the maintenance of health.*
The simplest examples that I can adduce of this, are in the hair and
teeth ; and in the process which I shall describe and illustrate with the
annexed diagram, we seem to have an image in which are plainly
marked, though, as it were, in rough outline, all the great features of
the process by which certain tissues are maintained.
An eyelash which naturally falls, or which can be drawn out without
pain, is one that has lived its natural time, and has died, and been
separated from the living parts. In its bulb such a one will be found
very different from those that are still living in any period of theii*
age. In the early period of the growth of a dark eyelash, we find its
outer end almost uniformly dark, marked only with darker short linear
streaks, and exhibiting no distinction of cortical and medullary sub-
stance. Not far from its end, however, this distinction is plainly
marked ; dark as the cortical part may be, the medullary appears like
an interior cylinder of much darker granular substance : and in a young
hair this condition is continued down to its deepest part, where it en-
larges to form the bulb. (Fig. 1, a.) Now this enlargement, which is
of nearly cup-like form, appears to depend on the accumulation of
round and plump nucleated cells, which, according to their position,
are either, by narrowing and elongation, to form the dry fibro-cells of
the outer part of the growing and further protruding shaft, or are to be
transformed into the air^holding cells of the medullary portion. At
this time of most active growth, both cells and nuclei contain abundant
pigment-matter, and the whole bulb looks nearly black. The sources
of the material out of which the cells form themselves are, at least,
two ; namely, the inner surface of the sheath, or capsule, which en-
velopes the hair, and the surface of the vascular pulp, which fits in a
conical cavity in the bottom of the hair-bulb.
Such is the state of parts so long as the growing hair is all dark. .
Bat, ^s it approaches the end of its existence, it seems to give tokens
of advancing age, by becoming gray. (Fig. 1, B, c.) Instead of the
almost jsudden enlargement at its bulb, the hair only swells a little, and
then tapers nearly to a point ; the conical cavity in its base is con-
tracted, and hardly demonstrable, and the cells produced on the inner
* Hunter (Works, vol. iii, p. 495), and Treviranus (Biolopie, b. iii, 482), may be thought
to have had some insight into this important law ; but the merit of having first maintained
in terms nearly similar to the above, and as more than an hypothesis, that " each part of the
organism has in individual life of its own," and " a limited period of existence," belongs to
Dr. Carpenter. — Prineiplet of Human Physiology, 3d edit. p. 623.
aurfacG of the capsule contain no particle of pigment. Still, for some
time it continues thus to live and grow, and we find that the vigor of
the conical pulp lasts rather longer than that of the sheath or capsule ;
for it continues to produce pigment-matter some time nftor the cortical
euhNtancc of the hair has been entirely white, and it is still distinct,
because of the pigment-cells covering its surface.
At length the pulp can he no longer discerned, and uncolored cells
atone are produced, and maintain the latest growth of the hair. With
these it appears to grow yet some further distance, for we see traces of
their elongation into fibres or fibro-cells, in lines running from the inner
surface of the capsule inwards and along the surface of the hair ; and
we can always observe that the diirk column of medullary air-containing
substance ceases at some distance above the lower end of the contractetl
hair-bulb. (C, D.)
The end of all is the complete closure of the conical cavity in which
the hair-pulp was lodged ; the cessation of the production of new cells ;
and the consequent detachment of the hair as a dead part, which now
falls by the first accident ; falls, sometimes, quite bare and smooth on
the whole surface of its white bulb, but sometimes bringing with it a
layer of cells detached from the inner surface of the capsule, (d.)
Such is the life of a hair and such its death ; which death, you see,
is natural, spontaneous, independent of exercise, or of any mechanical
external force, the natural termination of a certain period of life. Yet,
before it dies, provision is made for its successor ; for when- its growth
is failing, you often find, just below the base of the old hair, a dark
ITS NATURE, PURPOSE, AND CONDITIONS. 31
spot, the germ or young pulp of the new one ; it is covered with cells
containing pigment, and often connected by a series of pigment-cells
with the old pulp or capsule. (Fig. 1, c.) And this appears to be
produced by an increase in the growth of the cells at the bottom of the
hair-follicle, which cells Kolliker's observations have shown to be de-
rived partly from the soft round cells of the hair-bulb, and partly from
the adjacent outer root-sheath. By the subsequent elongation and
differentiation of these cells the new hair is formed.
I believe that we may assume an intimate analogy between the pro.
cess of successive life and death, which is here shown, and that which
is believed to maintain the ordinary nutrition of a part. It may be
objected, indeed, that the death and casting-out of the hair cannot be
imitated in internal parts ; but we are not without an example in which
the absorption of a worn-out internal particle is exactly imitated in
larger organs, at the end of their appointed period of life. I itdduce
the instance of the deciduous or milk-teeth.
We trace each of these developed from its germ, then each, having
gained its due perfection, retains for a time its perfect state, and still
lives, though it does not grow. But at length, as the new tooth comes,
the deciduous tooth dies, coincidently, not consequently ; or rather the
crown of the old tooth dies, and is cast out like the dead hair ; while
its fang, and the vascular and nervous pulp degenerate, and are ab-
sorbed. It is here especially to be observed, that the degeneration is
accompanied by some spontaneous transformation of the fang ; for it
could not be absorbed, unless it were first so changed as to be soluble.
And it is degeneration, not death, which precedes its removal; for
when a tooth-fang really dies, as that of the second tooth does in old
age, then it is not absorbed, but is cast out entire, as a dead part.
Such, or nearly such, it seems almost certain, is the process of nutri-
tion everywhere : these may be taken as types of what occurs in other
parts ; for these are parts of complex organic structure and composi-
tion, and the teeth-pulps, which are absorbed as well as the fangs, are
very vascular and sensitive, and therefore, we may be nearly sure, are
conformed to only the same laws as prevail in all equally organized
parts.
Nor are these the only instances that might be adduced. We see
the like development, persistence for a time in the perfect state, death,
and discharge, in all the varieties of cuticles ; and in the epidermis we
have, as in the teeth, an evidence of chemical change in the old cells,
in the very different influence which acetic acid and potash exercise on
them and on the younger cells, making these transparent, but leaving
them scarcely changed.
These things, then, seem to show that the ordinary course of each
elementary organ in the body, after the attainment of its perfect state
by development and growth, is, to remain in that state for a time ; then,
independently of the death or decay of the whole body, and, at least.
32 NUTRITION:
in a great measure independently of its own exercise or exposure to
external violence, to die or to degenerate ; and then, being cast out or
absorbed, to make way for its successor.*
It appears, moreover, very probable, that the length of life which
each part is to enjoy is fixed and determinate, though, of course, in
some degree, subject to accidents, which may shorten it, as sickness
may prevent death through mere old age ; and subject to the expendi-
ture of life in the exercise of function. I do not mean that we can as-
sign, as it is popularly supposed we can, the time that all our parts
will last ; nor is it likely that all parts are made to last an equal time,
and then to be changed. The bones, for instance, when once completely
formed, probably last longer than the muscles and other softer tissues.
But when we see that the life of certain parts is of determined length,
whether they be used or not, we may assume, from analogy, the same
of nearly all.
For instance, the deciduous human teeth have an appointed dura-
tion of life ; not, indeed, exactly the same in all persons, yet, on the
whole, fixed and determinate. So have the deciduous teeth of other
animals. And in all those numerous instances of periodical moulting,
of shedding of the antlers, of the entire desquamation of serpents, and
of the change of plumage in birds, and of the hair in mammalia ; what
means all this, but that these organs live their severally appointed
times, degenerate, die, are cast away, and in due time are replaced by
others ; which in their turn are to be developed to perfection, to live
their life in the mature state, and to be cast off? We may discern the
same laws of life in some elementary structures ; for example, in the
blood-corpuscles, of which a first set, formed from embryo-cells, disap-
pears at a certain period in the life of the embryo, being replaced and
superseded by a second set formed probably from lymph and chyle cor-
puscles. And in these, also, we may see an example of the length of
life of elemental parts being determined, in some measure, by their ac-
tivity in function ; for if the development of the tadpole be retarded, by
keeping it in a cold, dark place, and if, in this condition, the function
of the first set of blood-corpuscles be slowly and imperfectly discharged,
they will remain unchanged for even many weeks longer than usual ;
their individual life will be thus prolonged, and the development of the
corpuscles of the second set will be, for the same time, postponed. f
The force of these facts is increased by the consideration of the exact
analogy, the almost identity, of the processes of secretion and nutrition ;
for in no instance is the fact of this limited life of individual parts more
* It is not intended to be implied in the above paragraph, that in all the completely
formed tissues, such a bodily removal and replacement of whole structures take place as
we see in the epithelium cells. In the bones, nervous textures, and muscular fibres, for ex.
ample, the changes are undoubtedly molecular, the structure remaining, though the materials
which compose it are renewed.
t See Kirkes's Physiology, pp. 63 and 298, 4lh ed.
ITS NATURE, PURPOSE, AND CONDITIONS. 33
clearly shown than in the gland-cells, by which periodical secretions
are elaborated. The connecting link between such gland-cells and the
most highly organized parts, as well as a manifest instance of determi-
nate length of life and natural death, is found in the history of the ova.
These attain their maturity in fixed successive periods of days : they
are separated (as the materials of several secretions are) while yet living,
and with a marvellous capacity of development, if only they be impreg-
nated during the few days of life that remain to them after separation ;
but if these days pass, and impregnation is not effected, they die, and are
cast out as impotent as the merest epithelial cell."^
Now from these cases it is not by a far-fetched analogy that we as-
sume the like mortality in all other tissues, and that this is the princi-
pal source of impairment, and of change for the worse, which every
part of the body has within itself, even in the most perfect state, and
in the conditions most favorable to life. And I may anticipate a future
subject of consideration, by saying that the application of these truths
is of some importance in practical pathology ; inasmuch as the results
of this degeneration of parts at the close of their natural term of life,
may be mingled with the effects of all the morbid processes by which
the natural nutrition of a part is hindered or perverted. Hence, at
least in part, the long-continuing or permanent loss of power in an
organ (say a muscle) which has been disused, or has been the seat of
inflammation. This loss is not wholly due to a primary disease of the
fibre ; in part, it is because the inflammatory process and the organiza-
tion of the morbid exudation exclude the ordinary process of nutrition ;
and the muscular fibres, which now, in the ordinary course of life, de-
generate, are not replaced, or are imperfectly repaired.
Of the results of these natural and unrepaired degenerations of tis-
sues I shall speak more hereafter. Let me now consider the conditions
under which the repair of parts thus deteriorated is effected ; for it is
against the effects of these natural deteriorations that the process of nu-
trition in the adult is chiefly directed ; and it appears to be by the dis-
turbance or removal of certain necessary conditions, more often than
by any suspension or perversion of itself, that error is engendered in
the process of formation. And, in speaking of these conditions of
healthy nutrition, I shall take leave occasionally to diverge, even very
far, into the consideration of certain points of interest in the general
physiology of the process.
Doubtless the conditions necessary to the normal nutrition of parts
are very many ; but the chief of them are these four :
* The adjustment of the organic processes according to laws of time has been more fnlly
iUastrated in a discourse " On the Chronometry of Life," delivered at the Royal Institution,
April 8, 1859, an abstract of which appeared in the Journal of their Proceedings. The
subject has also been considered in the Croonian Lecture for 1857 (Proc. Roy. Soc., Lond.),
to which reference may be made for a discussion of the phenomena of nutrition, in the
rhythmically acting muscles, heart, diaphragm, &c.
S4 NUTRITION:
1. A right state and composition of the blood or other nutritive
material.
2. A regular and not far distant supply of such blood.
3. (At least in most cases) a certain influence of the nervous system.
4. A natural state of the part to be maintained.
And, first of the right state of the blood, I may observe that I use
the expression " right state*' rather than " purity," because, if the latter
be used, it seems to imply that there is some standard of composition to
which all blood might be referred, and the attainment of which is
essential to health ; whereas the truth seems rather to be, that, from
birth onwards, the blood and tissues of each creature are adapted to one
another, and to the necessary external circumstances of life, and that
the maintenance of health depends on the maintenance and continual
readjustment of the peculiarities on which this exact adaptation de-
pends.
The necessity for this right or appropriate state of the blood, as a
condition of healthy nutrition, involves of course the necessity for the
due performance of the blood-making and blood- purifying functions ; it
requires healthy digestion, healthy respiration, healthy excretion. Any
one of these being disturbed, the formative process in a part, or in the
whole body, may be faulty, for want of the appropriate material. But,
important as these are, we must not let the consideration of them lead
us to forget that there is something in the blood itself, which is at least
as essential to the continuance of its right and healthy state as these
are, and which is, indeed, often occupied in correcting the errors to
which these, more than itself, are subject ; I meHn the power of assimila-
tion or maintenance which the blood possesses, in and for itself, as
perfectly and at least as independently as any of the tissues. By this
it is, that notwithstanding the diversity of materials put into the blood,
and the diversity of conditions in which the functions ministering to its
formation are discharged, yet the blood throughout life retains, in each
person, certain characters as peculiar as those of his outer features for
the continual renewal of which it provides appropriate materials. And
by this assimilative power of the blood it is that the tissues are con-
tinually guarded ; for by it many noxious substances introduced into
the blood are changed and made harmless before they come to the
tissues ; nor can any substance, introduced from without, produce dis-
ease in an organ, unless it be such a one as can escape the assimilative
and excretory power of the blood itself.
In this maintenance is the chief manifestation of the life of the adult
blood ; a life, in all essential things, parallel and concurrent with that
of the tissues. For in the blood we may trace all those which we
recognize as signs and parts of life in the solids ; we watch its develop-
ment, its growth, its maintenance by the assimilation of things unlike
itself; we find it constituting an adapted purposive part of the organism ;
possessing organic structures ; capable of disease and of recovery ; prone
ITB NATDRB, PURPOSE, AND CONDITIONS.
85
to degeDeration and to death. In all these things, we have to study the
life of the blood aB we do that of the solid tissues ; the life, not only of
the structures of the blood, but of its liquid also; and as, in first
development, the blood and tissues are made, of similar materials, in
exact conformity with one another, so, through later life, the normal
changes of each concur to maintain a like conformity and mutual
adaptation. I cannot now dwell on these points;* but they will be
frequently illustrated in the following lectures, and some of them at
once, in what I have to say of the precision of adjustment in which the
"right state" of the blood consists.
Notwithstanding its possession of the capacity of maintenance, the
blood is subject to varions diseases, in consequence of which the nutri-
tion of one or more tissues is disordered. The researches of modem
chemistry have detected some of these changes ; finding excesses or
deficiencies of some of the chief constituents of the blood, and detecting
in it some of the materials introduced from without. But a far greater
number of the morbid conditions of the blood consist in changes,
from the discovery of which the
acntest chemistry seems yet far ^'S- ^■
distant, and for the illustration
and discussion of which we can-
not adopt the facts, though we
may adopt the language and the
analogies, of chemistry. It is in
such diseases as these that we
can best discern how nm is that
refinement of mutual influence,
bow exact and constant that
adaptation, between the blood
and tissues, on which health de-
pends.
I know no instance so well
adapted to illustrate this as the
examples of symmetrical dis-
eases. The nnifonn character
of such diseases is, that a cer-
tain morbid change of structure
on one side of the body is re-
peated in the exactly corres-
ponding part on the other side.
In the lion's pelvis, for example,
which is sketched in the an-
nexed diagram, Fig. 2, from a
tUWKt of p«rt of which ia given bjr Dr. Eirkea in his " Handbook of Pbjiiology," p. f
at ihe College in 184S,a
86 NUTRITION:
\
specimen (No. 3030) in the College Museum, multiform as the pattern
is, in which the new bone, the product of some disease comparable with
a human rheumatism, is deposited, — a pattern more complex and irre-
gular than the spots upon a mat, — there is not one spot or line on one
side which is not represented, as exactly as it would be in a mirror, on
the other. The likeness has more than daguerreotype exactness, and
was observed in numerous pairs of the bones similarly diseased.
I need not describe many examples of such diseases. Any out-pa-
tient's room will furnish abundant instances of exact symmetry in the
eruptions of eczema, lepra, and psoriasis ; in the deformities of chronic
rheumatism, the paralyses from lead ; in the eruptions excited by iodide
of potassium or copaiba. And any large museum will contain exam-
ples of equal symmetry in syphilitic ulcerations of the skull ; in rheu-
matic and syphilitic deposits on the tibise and other bones ; in all the
effects of chronic rheumatic arthritis, whether in the bones, the liga-
ments, or the cartilages ; in the fatty and earthy deposits in the coats
of arteries.
Now these facts supply excellent evidence of the refinement of the
aflSnities which are concerned in the formative process. Excluding,
perhaps, the cases of congenital defects that are symmetrical, and a few
which seem to depend on morbid influence of the nervous system, it
may be stated generally, that all symmetrical diseases depend on some
morbid material in the blood. You may find the proof of this position
in papers written simultaneously by Dr. William Budd and myself;*
and in Dr. Budd's essay you may find it nearly demonstrated, by a
masterly discussion of the subject, that in iA)st of these cases, the
morbid material enters into combination with the tissue which is dis-
eased, or with the organized product of the morbid process. NoW the
evident and applicable truth in all these cases is, that the morbid sub-
stance in the blood, be it what it may, acts upon and changes only cer-
tain portions of what we might suppose to be all the very same tissue.
Such a substance fastens on certain islands on the surfaces of two
bones, or of two parts of the skin, and leaves the rest unscathed :
and these islands are the exactly corresponding pieces upon op-
posite sides of the body. The conclusion is unavoidable, that these
are the only two pieces that arc exactly alike; that there was less
aflSnity between the morbid material and the osseous tisstie, or the
skin, or the cartilage, close by ; else it also would have been similarly
diseased. Manifestly, when two substances display different relations
to a third, their composition cannot be identical ; so that, though we
may speak of all bone or of all skin, as if it were all alike, yet there
are differences of intimate composition; and in all the body the only
parts which are exactly like each other, in their mutual relation with
the blood, are those which are symmetrically placed upon the opposite
* Medico-Chirurg. Trans, vol. xxv.
ITS NATURE, PURPOSE, AND CONDITIONS. 37
sides. No power of artificial chemistry can, indeed, detect the differ-
ence ; hut a morbid material can : it tests out the parts to which it has
the greatest aflBnity, unites with these, and passes by the rest.*
I might magnify the wonder of this truth by showing how exceed-
ingly small, in some of these cases, must be the quantity of the morbid
material existing in the blood. But I prefer to illustrate a fact which
singularly corroborates the evidence, afforded by symmetrical diseases,
of the refinement of the operations of the aflSnities, if we may so call
them, between the blood and the tissues. The fact is that of certain
blood diseases having " seats of election." For example, in another lion's
pelvis (No. 8024), diseased like that sketched above, not only is the
morbid product just as symmetrical, but its arrangement is exactly
similar ; hardly a spot appears on one pelvis which is not imitated on
the other. And these are only examples of a large class of cases of
syphilis, rheumatism, and various skin diseases, of which the general
character is, that the disease is much more apt to affect one certain por-
tion of a bone, or of the skin, or of some other tissue, than to attack
any other portion. We are all in the habit of using the fact as an aid
in diagnosis ; but we may have overlooked its bearing on the physiology
of nutrition. It proves, on the one hand, as the cases of symmetrical
diseases do, that the composition of the several portions of what we
call the same tissue is not absolutely identical ; if it were, these diseases
should affect one part of a bone or other tissue as often as another part,
or should affect all parts alike. And it proves, on the other hand, a
constant similarity, even an identity of the morbid material on which
each of these diseases depends, though it be produced in different indi-
viduals ; so that we may venture to predict, that whenever chemistry
shall discover the composition of these materials, it will be found as con-
stant and as definite as the composition of those inorganic substances
which the science has most successfully scrutinized.
Moreover, Dr. William Budd has proved that, next to the parts which
are symmetrically placed, none are so nearly identical in composition as
those which are homologous. For example, the backs of the hands and
of the feet, or the palms and soles, are often not only symmetrically,
but similarly affected with psoriasis. So are the elbows and the knees ;
* Some of the differences here noticed are not permanent, but may seem to depend on the
several parts of a bone, or of the skin of a limb (for example), being in different stages of
development or degeneration. The symmetrical parts of the tissue, being exactly alike, may
be simultaneously and equally affected by a disease, while other parts of the same remain
unaffected, till in the course of time, they attain, by development or degeneration, the very
eame condition as the parts first affected.. Then, if the morbid material still exist in the
blood, these parts also become diseased ; and so in succession may nearly the whole of a
tissue. This view agrees very well with the fact that symmetrical diseases of>en spread,
and so prove that a part which in one week or month is not susceptible of the influence of a
morbid material, may in the next, become as susceptible as that which was first afiected.
This susceptibility, however, may be due, not to normal changes, but to the influence which
the diseased portion of the tissue exercises on those around it.
38 CONDITIONS NECESSARY TO
and similar portions of the thighs and the arms may be found affected
with ichthyosis. Sometimes also specimens of fatty and earthy deposits
in the arteries occur, in which exact similarity is shown in the plan,
though not in the degree, with which the disease affects severally the
humeral and femoral, the radial and peroneal, the ulnar and posterior
tibial arteries.
To conclude, these symmetrical diseases with seats of election prove,
1st. That in the same person the only parts of any tissue which are
identical in composition are, or may be, first, those which occupy sym-
metrical positions on the opposite sides of the body ; and next, those
which are in serial homology.
2dly. That the portions of the bodies of different individuals which
are identical, or most nearly so, in composition, are those in exactly
corresponding positions.
3dly. That even in different individuals the specific morbid materials,
on which many of the diseases of the blood depend, are of identical
composition.
It would be foreign to my purpose to enter now upon all the subjects
of interest which are illustrated by these cases. I may refer you again
to the papers already mentioned, especially to Dr. Budd's. For the
present it will be sufficient if I have proved (without pretending to ex-
plain or describe) the perfect and most minute exactness of the adapta-
tion which, in health, exists between the blood and all the tissues ; and
that certain inconceivably slight disturbances of this adaptation may
be sources of disease. If this be proved, I shall not fear to be met
with an objection against too great refinement in what I shall next say
concerning some of the means by which that right state of the blood,
which is appropriate to the healthy nutrition of all the parts, is at-
tained and preserved.
LECTURE II.
THE CONDITIONS NECESSARY TO HEALTHY NUTRITION.
I NEED not dwell on the physiology of the process of digestion,
absorption, excretion, and others, which, on the large scale, serve in the
development and maintenance of the blood. The admitted doctrines
concerning these I must assume to be well known, while I proceed with
the consideration of those minuter relations in which the blood and the
several tissues exercise their mutual influence, and by which each is
maintained in its right state. And, first, let me endeavor to develop
a principle, the germ of which is in the writings of Treviranus. His
sentence is, that " each single part of the body, in respect of its nutri-
HEALTHY NUTRITION. 39
tion, Stands to the whole body in the relation of an excreted substance.'**
In other words, every part of the body, by taking from the blood the
peculiar substances which it needs for its own nutrition, does thereby
act as an excretory organ, inasmuch as it removes from the blood that
which, if retained in it, would be injurious to the nutrition of the rest
of the body. Thus, he says, the polypiferous zoophytes all excrete
large quantities of calcareous and siliceous earths. In those which
have no stony skeletons these earths are absolutely and utterly excreted ;
but in those in which they form the skeleton, they are, though retained
within the body, yet as truly excreted from the nutritive fluid and all
the other parts, as if they had been thrown out and washed away. So
the phosphates which are deposited in our bones are as effectually ex-
creted from the blood and the other tissues, as those which are discharged
with the urine.
But Treviranus seems not to have apprehended the full importance of
the principle which he thus clearly, though so briefly, stated ; for it
admits, I think, of far extension and very interesting application.
Its influence may be considered in a large class of out-growing tis-
sues. The hair, for example, in its constant growth, serves, not only
local purposes, but for the advantage of the whole body, in that, as it
grows, it removes from the blood the various constituents of its sub-
stance which are thus excreted from the body. And this excretory
office appears, in some instances, to be the only one by which the hair
serves the purpose of the individual ; as, for example, in the foetus.
Thus, in the foetus of the seals, that take the water as soon as they are
born, and, I believe, in those of many other mammals, though they are
removed from all those conditions against which hair protects, yet a
perfect coat of hair is formed within the uterus, and before, or very
shortly after, birth this is shed, and is replaced by another coat of
wholly different color, the growth of which began within the uterus.
Surely, in these cases, it is only as an excretion, or chiefly as such, that
this first growtli of hair serves to the advantage of the individual. The
lanugo of the human foetus is an homologous production, and must, I
think, similarly serve in the economy, by removing from the blood, as
so much excreted matter, the materials of which it is composed.
Further, I think we may carry this principle to the apprehension of
the true import of the hair which exists in a kind of rudimental state
on the general surface of our bodies, and to that of many other perma-
nently rudimental organs, such as the mammary glands of the male
and others. For these rudimental organs certainly do not serve, in a
lower degree, the same purposes as are served by the homologous parts
* Die Erschein: und Gesetze des oi^anischen Lebens, B. I, p. 401. In an article on
hereditary influences, in the Weatmintter Review^ Ju\y^ 1 856, and in his work on the Physi-
ology of Common Life, vol. i, p. 286, Mr. G. H. Lewes states that C. F. Wolff, and not Tre-
Tiianus, was the original expositor of the doctrine of complemental nutrition. — See Theoria
40 CONDITIONS NBCBSSARY TO
which are completely developed in other species, or in the other sex.
To say they are useless, is contrary to all we know of the absolute
perfection and all-pervading purpose of Creation : to say they exist
merely for the sake of conformity with a general type of structure,
seems unphilosophical, while the law of the unity of organic types is,
in larger instances, not observed, except when its observance contri-
butes to the advantage of the individual. Rather, all these rudimental
organs must, as they grow, be as excretions, serving a definite purpose
in the economy, by removing their appropriate materials from the blood,
and leaving it fitter for the nutrition of other parts, or by adjusting
the balance which might else be disturbed by the formation of some
oth^r part. Thus they minister to the self-interest of the individual,
while, as if for the sake of wonder, beauty, and perfect order, they
are conformed with the great law of the unity of organic types, and
concur with the universal plan observed in the construction of organic
beings.
And again, — the principle that each organ, while it nourishes itself,
serves the purpose of an excretion, has an application of peculiar inte-
rest in the history of development. For if it bcvinfluential when all the
organs are already formed, and are only growing or maintaining them-
selves, much more will it be so when the several organs are successively
forming. At this time, as each nascent organ takes from the nutritive
material its appropriate constituents, it will co-operate with the gradual
self-development of the blood, to induce in it that condition which is
essential or most favorable to the formation of the organs next in order
to be developed.
The importance of this principle will the more appear if we connect
with it another, equally characteristic of the minuteness of the relation
between the blood and the tissues, namely, that the existence of certain
materials in the blood may determine the formation of structures in
which they may be incorporated.
This seems to be established as a general law in pathology, by the
cases in which diseased structures evidently incorporate materials that
had their origin or previous existence in the blood. Such are most of
those inoculable and other blood-diseases in which morbid organisms are
produced; as vaccinia, variola, chancre, glanders, &c. The same law
may be made very probable in physiology also. For example, when
one kidney is destroyed, the other often becomes much larger, does
double work, as it is said ; and the patient does not suffer from the
retention of urine in the blood; the full meaning of which (a well-
known fact, and not without parallel) may be thus expressed : The prin-
cipal constituents of the urine are, we know, ready formed in the blood,
and are separated through the kidneys by the development, growth, and
discharge of the contents of the renal cells in which they are, for a
time, included. Now, when one kidney is destroyed, there must for a
time be an excess of the constituents of urine in the blood ; for since
HEALTHY NUTRITION. 41
the separation of urine is not mere filtration, the other kidney cannot
at once, and without change of size, discharge a double quantity. What,
then, happens ? The kidney grows ; more renal cells develop, and dis-
charge, and renew themselves; in other words, the existence of the
constituents of the urine in the blood that is carried to every part deter-
mines the formation of the appropriate renal organs in the one appro-
priate part of the body.
An analogous fact is furnished by the increased formation of adipose
tissue in consequence of the existence of abundant hydrocarbon princi-
ples in the blood. Another, bearing on the same point, though not ad-
mitting of definite description, is the influence exercised by various diets
in favoring the especial growth of certain tissues ; as the muscles, the
bones, the hair, or the wool. Similar facts are yet more evident in the
cultivation of vegetables, to which various materials are supplied, in the
assurance that certain corresponding tissues will be consequently
formed. And an evident illustration of the same principle is in the
abundant formation of fruit on a branch in which the matured sap has
been made t9 accumulate by ringing.
I add again, on this point, as on a former one, that the case as con-
cerning nutrition is remarkably corroborated by the observation of simi-
lar facts in instances of secretions. Thus, the excesses of albuminous
materials taken in food, if they be not incorporated in the more highly
organized tissues, are excreted; that is, they, or the materials into
which they are transformed, enter into the construction of the transient
tissue of the kidney or some excretory organ. The constituents of food
plainly as they influence the quantity and quality of milk, do so only
by afiecting, after their admission into the blood, the formation of the
transient parts of the mammary gland-tissue. Medicines, such as diu-
retics, that are separated from the body by only certain organs, are, for
a time, we must believe, incorporated in the tissues of those organs.
These facts seem enough to make highly probable the principle I
mentioned, namely, that the existence of certain materials in the blood
may determine the formation of structures into the composition of which
those materials may enter. At any rate, they make it nearly certain
for the more lowly organized tissues, and for the products of disease ;
and hence, by analogy, we may assume it for the other tissues. Even
for the very highest we may safely hold that a necessary condition of
their formation is this previous existence of the peculiarly appropriate
materials in the blood.
Now, if we combine these two principles — first, that the blood is defi-
nitely altered by the abstraction of every material necessary for the
nutrition of a part, and secondly, that the existence of certain materials
in the blood induces the formation of corresponding tissues, we may
derive from them some very probable conclusions bearing on the ques-
tions before us. First, we may conclude that the order in which the
several organs of the body appear in the course of development, while
4
42 CONDITIONS NECESSARY TO
it is conformable with the law of imitation of the parent, and with the
law of progressive ascent towards the higher grade of being, is yet in
part, and in this more directly, the result of necessary and successive
consequences ; the formation of one organ, or series of organs, inducing
or supplying a necessary condition for the formation of others, by the
changes successively produced in the composition of the blood, or other
nutritive material. In other words, we may hold, in accordance with
these principles, that the development of each organ or system co-ope-
rating with the self-development of the blood, prepares it for the forma-
tion of some other organ or system, till, by the successive changes thus
produced, and by its own development and increase, the blood is fitted
for the maintenance and nutrition of the completed organism.
Secondly, I think that these principles may be applied to individual
instances. They may suggest that certain organs stand, in their
nutrition, in a complemental relation to each other ; so that neither of
them can be duly formed or maintained in healthy structure, unless the
right condition of the blood be induced and preserved by the formation
of the other.
It is, of course, very diflScult, or even impossible, to find instances by
which this theory of complemental nutrition can be proved; while,
really, we neither know exactly what materials are necessary for the
formation of any organ, nor have the means of detecting the presence
of more than a very few of them in the blood. It is very well for the
discussion of certain parts of physiology to say, for instance, that a
muscle mainly consists of a material like fibrine ; but when we are con-
sidering the physiology of the formation of organs, we must remember
that in every muscular fibre there are at least three different com-
pounds,— those of the sarcolemma, of the nucleus, and of the fibril ; that
these are all equally essential to the formation of the fibre ; and that
we know not the composition of any one of them, nor could detect the
absence of any one of them from the blood, though the result of that
absence might be to render the formation of a muscular fibre impossible.
But, though it may lack direct evidence, the theory seems, in itself,
probable ; and there are many facts which we can explain by it so well,
that they become evidence for it : which facts, moreover, are fair
subjects for theoretical explanation, since, I believe, they are admitted
to be as yet wholly unexplained.
Among these is the general fact that a great change in nutrition
rarely takes place in one organ aU a time, but usually aflfects simultane-
ously two or more parts, between whose nutrition there is a manifest
and constant connection, although there is little or no relation between
their external functions. Such, to take an instance from a large class,
is the connection between the growth of various appendages of the
integuments, and the development or maintenance of the genital organs.
This appears to be a general rule. The growth of the beard at the
period of puberty in man, with which we are so familiar, is more
HEALTHY NUTRITION. 43
instructively represented in many animals; especially in birds. In
these, as you know, at the approach of every breeding-time, the genital
organs begin to develop themselves for the season, as in man they do
for the whole time of vigorous life. And commensurately with this
development, the plumage (especially in the male bird) becomes brighter
and more* deeply colored, both by the growth of new feathers and by
the addition of color to the old ones. The height and perfection of the
plumage are coincident with the full development and activity of the
reproductive organs ; but a« in man, when the development of the genital
organs is prevented, that of the beard and all the other external sexual
characters is, as a consequence, hindered, so, in birds, when the breeding
season ends, and the sexual organs pass gradually into their periodic
atrophy, at once the plumage begins to assume the paler and more sober
colors which characterize the barrenness of winter.
So it is, also, at least in certain instances, in the mammalia, of which
we have interesting evidence, in the. history of specimens presented to
the museum of the College by Sir Philip Egerton. These show that if
a buck be castrated while his antlers are growing and still covered with
the velt, their growth is checked, they remain as if truncated, and
irregular nodules of bone project from their surfaces. Or, if the castra-
tion be performed when the antlers are full-grown, these, contrary to
what Redi said, are shed nearly as usual at the end of the season ; but
in the next season only a kind of low conical stumps are formed, in the
place of antlers.'*'
I need not multiply examples : it is a general fact, that the develop-
ment and activity of the reproductive organs have, as a consequence, or
as a necessary coincidence, a peculiar development and active growth
or nutrition of certain other structures ; which structures, therefore,
form the external sexual characters, though their external functions
stand in no apparent, often in no conceivable, connection with the
generation of the species. The fact is not hitherto explained ; it is
explicable on the theory of complemental nutrition, by believing that
the materials which, in the formation of these organs of external sexual
character, are removed from the blood, leave or maintain the blood in
the state necessary for the further development, growth, and active
function of the proper sexual or reproductive organs. In other words,
I would say, that where two or more organs are thus manifestly con-
nected in nutrition, and not connected in the exercise of any external
office, their connection is because each of them is partly formed of
materials left in the blood on the formation of the other ; and each,
at the same time that it discharges its own proper and external office,
* This formation of imperfect antlers may depend on the accessory organs of reproduction
being deyeloped ; for these would not necessarily fail to be developed because the testicles
were extirpated. And that the difference caused by castration is not due to the disturbance
of nerroos sympathies, is proved by the absence of any similar effect when the testes are
only trani^lanted. — See Berthold in Muller't Arehiv, 1849| p. 42.
i
44 CONDITIONS NECESSARY TO
maintains the blood in the condition most favorable to the formation of
the other.
If this theory be admissible, we may find through it the meaning of
the commensurate development and nutrition of many other organs,
which in their external functions appear unconnected. Such are the
concurrent development and activity of the thymus gland, and the air-
breathing organs, during the body's growth ; of the thyroid gland and
the brain (instances of commensurate development cited by Mr. Simon) ;*
of the spleen and pancreas (as pointed out by Professor Owen) ; and, I
would add, of the embryo and the mammary gland ; for the same theory
may hold true concerning the formation of certain organs which are,
finally, connected in their external functions.
In these, and other like cases, I think it will be hereafter proved that
the several organs are in their nutrition complemental, that the forma-
tion of each leads to the production of some material necessary for the
construction of the other ; and that, as we may be sure of Treviranus'
law, in general, — that each organ of the body, while it nourishes itself,
is in the character of an excretion towards all the rest, — so, we may be-
lieve, more particularly, that certain organs are, mutually, as excre-
tions from each other.f
But, thirdly, if there be any probability in the principles I have en-
deavored to illustrate, they must deserve careful consideration in the
pathology of the blood. I shall have to illustrate them in this view in
ifuture lectures. At present I will only suggest that if each part, in its
normal nutrition, is as an excreting organ to the rest, then the cessa-
tion, or perversion, of nutrition in one must, by no vague sympathy,
but through definite change in the condition of the blood, afiect the nu-
trition of the rest, and be thus the source of " constitutional distur-
bance." If, in health, there be such a thing as complemental nutri-
tion, it must, in disease, be the source of many sympathies in nutrition
between parts which are not specially connected through the nervous
system. If the condition of the blood can, in favorable circumstances,
determine the formation of organisms incorporating its materials, we
may study the characteristic structures of specific diseases as the evi-
dences of corresponding conditions of the blood, and as organs which,
by removing specific materials from the blood, afiect its whole constitu-
tion, and either restore its health, or produce in it secondary morbid
changes.
♦ Essay on the Thymus Gland ; and Philosophical Transactions, 1844, Part 2.
t Many of the phenomena, for which the above theory is offered as an explanation, would
be doubtless looked upon by Mr. Darwin, in conformity with his own peculiar views of the
origin of species, as due to hereditary transmission : many of the structures having now no
direct relation to the habits of life of each species. But as has been pointed out by Profes-
sor Rolleston, in an able article in the Natural History Review^ 1861, p. 484, all of the above
instances cannot be brought under ^hat head, and the explanation given in the text is the one
that is best warranted by the present state of our knowledge.
HEALTHY NUTRITION. 45
The extent of application that these principles admit of will, I trust,
justify the distance to which I may seem to have diverged from my
starting-point. Let me now return to it, and remind you that this long
discussion grew out of the consideration of the first condition necessary
for healthy nutrition, — namely, the right state of the blood ; a state
not to be described merely as purity, but as one of exact adaptation to
the peculiar structure and composition of the individual : an adaptation
so exact that it may be disturbed by the imperfect nutrition of a single
organ, and that for the maintenance of it against all the disturbing
forces of the outer life of the body nothing can suffice except continual
readjustment by the assimilative power of the blood itself.
The second condition of which I spoke as essential to the healthy
process of nutrition is —
A regular supply of appropriate blood in or near the part to be
nourished.
The proofs of the necessity of this condition must be familiar to all.
Instances will at once occur to your minds in which too little blood
being sent to a part it has suffered atrophy, or degeneration : others,
in which the supply being wholly cut off, mortification has ensued :
others, in which the blood, being stagnant in a part, has not efficiently
contributed to its nutrition.
If I can give interest to this part of the subject at all, it is only by
adducing interesting examples of the fact. Reserving for future lec-
tures the examples of merely diminished and of perverted nutrition, I
will mention now only some of the specimens in the Museums I have
chiefly studied, which illustrate how the process of nutrition is wholly
stopped by the absence or deficiency of fresh blood.
One of Mr. Swan's donations to the College Museum (No. 1821) is
the larynx of a man who while in low health, cut his throat, and suf-
fered so great a loss of blood that the nutrition became impossible in
one of those parts to which blood is with most difficulty sent ; and before
he died, his nose sloughed.
The case is like one which, you may remember, is recorded by Sir
Benjamin Brodie.* A medical man wished to be bled, in a fit of ex-
ceeding drunkenness; and some one bled him, bled him to three pints.
He became very ill, and next day both his feet were mortified from the
extremities of the toes to the instep.
A specimen (No. 141), presented by Mr. Guthrie, exhibits a morti-
fied, t. e. a completely unnourished leg, from a case in which the femo-
ral artery was obliterated near the groin, through disease of its coats.
The leg was amputated by Mr. Guthrie, with justifying success ; for
the stump, though cut at some distance below the obliteration of the
artery, did not slough ; the collateral circulation was sufficient for its
nutrition ; and the patient, an elderly lady, died only of exhaustion.
* Lectures on Pathology and Surgery, p. 350.
46 CONDITIONS NECESSARY TO
For a similar, and very rare example of sloughing after the oblitera-
tion of a main artery, I may refer to the case described by Mr. Vin-
cent, of a large slough in the very substance of one of the hemispheres
of the cerebrum, in consequence of a wound of the supplying common
carotid, a wound made by a tobacco-pipe thrust into the bifurcation of
the carotid, and nearly closing its channel.*
A specimen in the Museum of St. Bartholomew's Hospital (Series i,
134) exhibits an instance of dry gangrene, occurring in very unusual
circumstances. A woman, 48 years old, died, under the care of Mr.
Earle, having received some injury of the femur eighteen months before
death. Whether it were a fracture, or, indeed, what it was, cannot now
be said; but the injury was followed by enlargement of that portion of
the wall of the femur with which the artery and vein are nearly in con-
tact, as they pass in the sheath of the triceps adductor muscle. At
this part, then, the vein is compressed, and the artery, though not dis-
tinctly compressed, appears to have been hindered from enlarging. The
consequence was dry gangrene of the leg, which slowly destroyed life,
and which had no other apparent cause than this.
And, lastly, let me refer to two specimens, which are as interesting
in the history of surgery as in pathology. One is a tibia and fibula,
the lower ends of which, together with the whole foot, perished in con-
sequence of the obstruction of the circulation by an aneurism in the
ham. It is a Hunterian specimen in the College Museum (No. 710) :
and surely we may imagine that sometimes Mr. Hunter would contem-
plate it with pride to think how rare such things would be in after-
times. In strong contrast is this other specimen: the limb of a man
who once had an aneurism, like the one which in the former case was
so destructive, and on whom Hunter was permitted to confer fifty years
of healthy life by his operation of tying the artery at a distance from
the diseased part. The Museum of St. Bartholomew's owes this rare
specimen and most interesting relic to the zeal of my colleague, Mr.
Wormald. The patient was the fourth on whom Mr. Hunter performed
his operation. He was thirty-six years old at the time ; and though
the tumor was not large, yet the whole leg was swollen, the veins were
turgid, and he was exhausted, and in such bad health, that the case
seemed desperate; but he recovered, and lived, as I have said, fifty
years. The artery was tied in the sheath of the triceps muscle ; and in
this operation, for the first time, Mr. Hunter did not include the vein
in the ligature. He thus diminished exceedingly the danger of the
defective supply of arterial blood. The preparation shows the whole
length of the artery obliterated, from the origin of the profunda to that
of the anterior tibial, and the aneurism al sac, even after fifty years, not
yet removed, but remaining as a hard mass like an olive. f
* Medico-Chirurgical Transactions, vol. xxix, p. S8.
t The preparation is in Ser. 13, Siib-Ser. F. No. 4. The case is in the Transactions of a
Society for the' Improvement of Medical and Surgical Knowledge, vol. i, p. 138 ; and in
Hunter's Works, vol. iii, p. 604.
HEALTHY NUTRITION. 47
Now, the supply of appropriate blood, of which these specimens prove
the necessity, must be in or near the part to be nourished. We cannot
exactly say how near it must be, but, probably, all that is necessary is,
that the nutritive material should admit of being imbibed in sufficient
quantity into the substance of the part. For imbibition must be re-
garded as the means by which all parts supply themselves with nutri-
tive matter : thus deriving it from the nearest bloodvessels, and the
bloodvessels themselves being only the channels by which the materials
are brought near. The bloodvessels thus serve alike for the nutrition
of the vascular, and, as we call them, the non-vascular parts ; the
difference between which parts, in this regard, is really very little. For
in both cases the bloodvessels He outside the textures to which they
convey the nutritive fluid, and though, in the vascular parts, this fluid
is carried in streams into their interior, whilst in the non-vascular it
flows only on or near the surface, yet, in both alike, the parts to be
nourished have to imbibe the nutritive fluid, and the business of forma-
tion is outside the vessels. The distance between the bloodvessels and
the textures in the two cases is thus simply a difference of degree.
Thus in a highly vascular glandular organ, e, g,^ a salivary gland, the
bloodvessels are separated from the active secreting cells merely by
the thin limiting membrane of the gland-vesicles. In a muscle, again,
whilst the fibrils at the periphery of a fibre are separated from the
bloodvessels only by the thickness of the sarcolemma, those in the very
centre are removed to a greater distance from them. In the osseous
tissue, when it exists in thin layers, as in the lachrymal and turbinated
bones, the bloodvessels do not pass into the interior, but lie in the
mucous membrane on the surface. On the other hand, when it exists in
masses, as in the stronger bones, bloodvessels run into the Haversian
canals in its substance. Thus the same tissue yields an illustration of
a vascular and non-vascular texture. In both forms of the tissue the
mode in which the nutriment is obtained is the same ; in both the
vessels are at some distance from the texture. In adaptation to its
density, and consequent comparative impermeability, the osseous tissue
possesses a peculiar system of canals and spaces, termed canaliculi and
lacunae, which communicate, not merely with each other, but with the
canals in which the bloodvessels lie. Along these the nutritive fluid
flows; they bring it into closer relation with the ultimate texture, and
facilitate its imbibition. In the dentine of a tooth a corresponding
system of canals is met with, the dentine tubes, which convey the
nutritive fluid not only to the ivory itself, but to the enamel and tooth
bone.
The non-vascular epidermis, again, though no vessels pass into its
substance, imbibes nutritive matter from those which lie in the subjacent
cutis, and maintains itself and grows. Cartilage, similarly, is nourished
by the bloodvessels of the perichondrium and the adjacent bone. The
cornea, crystalline lens, vitreous humor, peripheral part of the umbi-
48 CONDITIONS NECESSARY TO
Ileal cord, are frequently cited as still more strongly marked examples
of non-vascular parts. In most of these, as well as in the fully formed
tendon, a system of anastomosing cells, the connective tissue corpuscles,
has been of late years described by Virchow, which, probably, like the
lacunae and canaliculi of bone, serve to transmit through their com-
municating processes the nutritive fluid to the more intimate parts of
the texture.*
This mode of nutrition by imbibition in all the forms of tissue it is
worth remembering ; else we cannot understand how the non- vascular
tissues, such as the cornea, the hair, the articular cartilages, and the
various cuticles, should be liable to diseases proper to themselves,
primarily and independently. And, except by thus considering the
subject, we shall not be clear of the error and confusion which result
from speaking of the "action of vessels,*' as if the vessels really made
and unmade the parts. We have no knowledge of the vessels as any-
thing but carriers of the materials of nutrition to and fro. They only
convey and emit the " raw material ;'* it is made up in the parts, and in
each after its proper fashion. The real process of formation of tissues
is altogether extra-vascular, even, sometimes, very far extra-vascular ;
and its issue depends in all cases chiefly, and in some entirely, on the
affinities (if we may so call them) between the part to be nourished and
the nutritive fluid.
*
The third condition essential to the healthy nutrition of parts is a
certain influence of the nervous system. It may be held, I think, that
in the higher vertebrata some nervous force is habitually exercised in
the nutrition of all the parts in or near which nerves are distributed ;
and that it is exercised, not merely in affecting or regulating the size
of the bloodvessels of the part, but, with a more direct agency, as being
one of the forces that concur in the formative process.
Of late years, a current of opinion has run against the belief of this ;
and, of those who admit some influence of the nervous system upon the
nutrition of parts, many do it, as it were, grudgingly and doubtfully.
They hold that at most the influence is exercised only indirectly, through
the power which the nervous system has of affecting the size of the
bloodvessels; or that the nervous system influences only the degree
without affecting at all the mode of nutrition in a part.
One chief argument against the belief that the nervous force has a
direct and habitual influence in the nutritive processes is, that in plants
and the early embryo, and in the lowest animals, in which no nervous
system is developed, all nutrition goes on well without it. But this is
no proof that in animals which have a nervous system, nutrition is
independent of it : rather, even if we had no positive evidence, we might
* Professor Owen appears to have been the first to suggest the existence of a tubular
system in tendon, similar to the lacunary and canalicular system in bone and the dentinal
tubes in teeth. — Leet. on Comp. Anat. 1846, p. 29.
HEALTHY NUTRITION. 49
assume that in ascending development, as one system after another is
added or increased, so the highest, and highest of all, the nervous
system, would be inserted and blended in a more and more intimate
relation with all the rest. This would, indeed, be only according to the
general law, that the interdependence of parts augments with their
development : for high organization consists not in mere multiplication
or diversity of independent parts, but in the intimate combination of
many parts in mutual maintenance.
Another argument implies that the nervous force can manifest itself
in nothing but impressions on the mind and muscular contraction-force.
So limited a view of the convertibility of nervous force is such a one
as the older electricians would have held, had they maintained that the
only possible manifestations of electricity were the attractions and
repulsions of light bodies, or that the electric force could never be made
to appear in the form of magnetism, of chemical action, or of heat. We
are too much shackled with these narrow dogmas of negation. The
evidence of the correlation and mutual convertibility of the physical
^ forces might lead us to anticipate a like variety of modes of manifesta-
tion for the nervous and other forces exercised in the living body.*
We might anticipate, too, that, as the nervous force has its origin in the
acts of nutrition by which the nerve-substance is formed, so, by recipro-
cal action, its exercise might affect the nutritive acts. As (for illustra-
tion sake) the completed blood affects all the processes by which itself
was formed, so, we might suppose, would the nervous force be able to
affect all the acts of which itself is the highest product.
But we need not be content with these probable deductions concern-
ing the direct influence of the nervous force on the nutritive process.
The facts bearing on the question seem sufficient for the proof.
A first class of them are such as show the influence of the mind upon
nutrition. Various conditions of the mind acting through the nervous
system, and by nervous force, variously affect the formative processes
in the whole body. There is scarcely an organ the nutrition of which
may not thus be affected by the mind. It is hardly necessary to adduce
examples of a fact so often illustrated ; yet I may mention this one :
Mr. Lawrence removed, several years ago, a fatty tumor from a
woman's shoulder ; and when all was healed she took it into her head
that it was a cancer and would return. Accordingly, when by accident
I saw her some months afterwards, she was in a workhouse, and had a
large and firm painful tumor in her breast, which, I believe, would have
been cut out, but that its nature was obscure, and her general health
was not good. Again, some months afterwards, she became my patient
at the Finsbury Dispensary : her health was much improved, but the
hard lump in her breast existed still, a^ large as an egg, and just like
a portion of indurated mammary gland. Having heard all the account
* See Carpenter on the Mutual Relation of the Vital and the Physical Forces, PhiL
Trans^ 1850, and General Physiology, p. 34.
50 CONDITIONS NECESSARY TO
of it, and how her mind constantly dwelt in fear of cancer, I made bold
to assure her, bj all that was certain, that the cancer, as she supposed
it, would go away ; and it did become very much smaller without any
help from medicine. As it had come under the influence of fear, so it
very nearly disappeared under that of confidence. But I lost sight of
her before the removal of the tumor was complete.
The other classes of cases are those in which the influence of the
nervous system alone, independent of the Mind, is shown. Of course,
such cases can only be drawn from those of abstraction or perversion of
the nervous influence ; and the effects of these are most plainly expressed
in the nutrition of parts exposed to external agencies, as the integu-
ments generally, the extremities, and other external parts ; but we may
fully believe, that what is observed in these, occurs also, in correspond-
ing measure, in more deeply-seated parts.
Now, for the results of the abstraction or diminution of nervous force,
I cite the following from among many similar facts : In the Museum
of St. Bartholomew's (Ser. 9, No. 9) is an example of central pene-
trating ulceration of the cornea, in consequence of destruction of the
trunk of the trigeminal nerve, by the pressure of a tumor near the
pons.* The whole nutrition of the corresponding side of the face was
impaired ; the patient had repeated attacks of erysipelatous inflamma-
tion, bleeding from the nose, and, at length, destructive inflammation of
the tunics of the eye, and this ulceration of the cornea.
In the College Museum (No. 2177) is the hand of a man, whose case
is related by Mr. Swan, the donor of the preparation. The median
nerve, where it passes under the annular ligament, is enlarged with
adhesion to all the adjacent tissues, and induration of both it and them.
A cord had been drawn very tight round this man*s wrist seven years
before the amputation of the arm. At this time it is probable the
median and other nerves suffered injury ; for he had constant pain in
the hand after the accident, impairment of the touch, contraction of the
fingers, and (which bears most on the present question) constantly
repeated ulcerations at the back of the hand.
Mr. Hilton has told me this case: A man was at Guy's Hospital,
who, in consequence of a fracture at the lower end of the radius,
repaired by an excessive quantity of new bone, suffered compression of
the median nerve. He had ulceration of the thumb, and fore and
middle fingers, which resisted various treatment, and was cured only by
so binding the wrist that the parts on the palmar aspect being relaxed,
the pressure on the nerve was removed. So long as this was done, the
ulcers became and remained well; but as soon as the man was allowed
to use his hand, the pressure on the nerves was renewed, and the
ulceration of the parts supplied by them returned.
Mr. Traversf mentions a case in which a man had paraplegia after
* The case is related by Mr. Stanley in the Medical Ocutette^ vol. i, 531.
t Further Inquiry concerning Constitutional Irritation, p. 436.
HEALTHY NUTRITION. 51
fracture of the lumbar vertebrse. He fractured at the same time his hu-
merus and his tibia. The former, in due time, united ; the latter did not.
Mr. De Morgan'*' has related a similar case. A man fractured his
twelfth dorsal vertebra, and crushed the cord; dislocated his left
humerus, and fractured fourteen ribs and his left ankle. He lived
eighteen days, during which the reparative process was active at the
injuries above the damage of the cord, but seemed to be wholly wanting
at those below it.
Sir B. C. Brodie mentions having seen mortification of the ankle
begin within twenty-four hours after an injury of the spine.f
It would be easy to multiply facts of this kind, without adducing
instances of experiments on lower animals, which, though they be cor-
roborative, cannot be fairly applied here. I will only refer in general
to the numerous recorded examples of the little power which paralyzed
parts have of resisting the influence of heat ; of the sloughing after
injury of the spinal cord ; of the slower repair and reproduction of parts
whose nerves are paralyzed or divided ; all which facts alike contribute
to prove that the integrity of the nervous centres and trunks which
are in anatomical relation with a part, is essential to its due nutrition,
or to its capacity of maintaining itself against the influence of external
forces, which capacity is itself an expression of the formative power.
Lastly, for cases illustrating the effects produced in nutrition by
disturbances of the nervous force, I must refer to the Lectures on
Inflammation. At present, I can only allude to the cases of inflamma-
tion of the conjunctiva excited by stimulus of the retina ; of inflamma-
tion of the testicle in consequence of mechanical irritation of the
urethra ; of the vascular congestion which is instantly produced around
a killed or intensely irritated part, or in and around a part in which
paroxysms of neuralgia are felt; of the inflammations whose range
seems to be determined by the course of distribution of nerves, as in
Herpes Zona.;^ In all these cases I know no explanation for the dis-
turbance of nutrition except that it is the consequence of the nervous
force in the part being directly, or by reflection, disturbed.
The value of all these facts is strengthened by the consideration of
the manifold and distinct influences of the nervous force upon secretion ;
for the process of secretion is so essentially similar to that of nutrition,
that whatever can be proved of the method of one might be inferred for
that of the other. And I think the proof of the direct influence of the
nervous force upon the formative process would be thus beyond question,
if it were not for the inconstancy of the results of injury of the spinal
cord and nerves. Even in the warm-blooded animals the division of
* London Medical and Surgical Journal, Jan. 4, 1834.
t Lectures on Pathology and Surgery, p. 309.
X Some curious cases have been recorded by Dr. Charcot, in Brown-S^quard's Journal
(January, IS59), where irritation of certain of the nerves of the limbs was followed by
eroptions on the portions of skin supplied by those nerves.
52 CONDITIONS NECESSARY TO
the cord does not always retard the healing of injuries in the paralyzed
limbs ; sometimes it scarcely affects any part of their nutrition ; and
even in man, healing may be effected in paralyzed limbs after injuries,
though they be produced by such trivial causes as would not have dis-
turbed the nutrition of sound limbs. I remember a man with nearly
complete paraplegia and distorted feet, the consequence of injuries of
the spine, in whom some tendons were subcutaneously divided, and
appeared to be healing ; but a bandage being applied rather tightly,
sloughing ensued at the insteps, on which the chief pressure fell, and
extended widely and deeply to the ankle-joints. Both the dorsal
arteries were laid open when the sloughs separated, and both the ankle-
joints, and the case presented a most striking example of the defective
self-maintenance of paralyzed parts. But granulations formed after the
separation of the sloughs, and the healing process went on slowly, but
uninterruptedly, till all was covered in with a well-formed scar. In
another case, a girl, with softening of the brain, had sloughs on nearly
every part of the body that was subject to even slight pressure : for
instance, on the back of her head resting on the pillow, on her elbows
and heels ; and yet, while several of these sloughs were extending with
fearful rapidity, an ulcer, which had remained after the separation of a
slough over the patella, healed perfectly.
Such cases as these seem incongruous in their several parts, and
irreconcilable with the general rules which I previously illustrated. I
cannot attempt to explain them ; but neither can I think that they
materially invalidate the rule.*
* Much of what seemed to be inexplicable in the variety of consequences of injury done
to the nervous system, is explained by Brown-S^quard (Journal de la Physiologie, Jan.
1859)! He has shown that in estimating the influence of the nervous system on nutrition,
we must distinguish between the effects produced by irritation of the spinal cord and nerves,
which occ-asion morbid action in a part, and those due to simple cessation of action ; as when
the cord, or the nerve going to a part, is divided. Where there is irritation of the nervous
system, as when the cord is pressed upon by a fractured spine, or other morbid cause, or a
nerve is compressed by a tumor or inflammatory adhesion, then ulceration and gangrene
may be set up soon after the occurrence of the lesion. On the other hand, when there is a
cessation of action in a part, due to the withdrawal of the nervous influence, as in section
of a nerve, then a slow and simple atrophy takes place. This explanation, however, hardly
appears to be applicable to all cases, for in the one cited above, the process of repair fol-
lowed that of rapid sloughing, without any apparent change in the state of the nervous
organs.
All that can be said against the participation of the nerve-force in the process of nutrition
may be found in Virchow (Cellular Pathologic, Lecture 14). But his negatives, numerous
though they are, are not sufficient to prevail against the more numerous positive experi-
ments which have been made of late years. Bernard, Waller, Brown-S^quard, Budge,
Schifl!^ Wharton Jones, and Lister, have proved to a complete demonstration that the nervous
system exercises a most important influence over the condition of the bloodvessels of a part
The general result of their experiments has been to show that enlargement of the blood-
vessels, a more rapid flow of blood, increased redness and temperature, rapidly follow the
division of the nerves. The converse of the above, namely, contraction of the bloodvessels,
pallor, and diminished temperature, occur, when, after division, galvanism is applied to the
nerves going to a part. Lister (Phil. Trans. 1858) has shown that the controlling power is
not exercised exclusively by any single part of the nervous axis, but that the function is ap-
HEALTHY NUTRITION. 53
Let me add further, that no tissue seems to be wholly exempt from
the influence of the nervous force on its nutrition. In the cuticle it is
manifest ; and for its influence in acting even through a considerable dis-
tance, I may mention a case, which is also in near relation to those in
which the hair grows quickly gray, in mental anguish. A lady, who is sub-
ject to attacks of what are called nervous headaches, always finds in the
morning after such a one, that some patches of her hair are white as if
powdered with starch. The change is effected in a night, and in a few
days after, the hairs gradually regain their dark brownish color.
If, now, we may hold this influence of the nervous system to be
proved, we may consider the question, through what class of nerves is
the nutritive process influenced ?
Indirectly, it is certain that the motor or centrifugal nerves may in-
fluence it ; for when these are paralyzed, the muscles they supply will
be inactive, and atrophy will ensue, first in these muscles : then in the
bones (if a limb be the seat of the paralysis), for the bones, in their nu-
trition, observe the example of their muscles : and finally, the want of
energy in the circulation, which is in some measure dependent on mus-
cular action, will bring about the atrophy of the other tissues of the
part. Hence, after a time, the evidences of paralysis of the facial
nerve may be observed in nearly all the tissues of the face.
But the effects of the destruction of the trigeminal nerve, while the
motor nerves of the parts which it supplies are unimpaired, prove that
a more direct influence is exercised, through sensitive or sympathetic
nerves. The olfactory, optic, third, fourth, sixth, and facial nerves
may be one and all destroyed, yet no disturbance of the nutrition of the
nose or eye may ensue. After destruction of the facial, indeed, there
parently regulated by the whole length of the cord, and the posterior part of the brain. His
experiments would also render it probable that there is in addition, a coordinating gan-
glionic apparatus in the part itself, which, under special conditions of direct irritation, is
capable of independent action. Of great value, also, in their relation to this important sub-
ject, are the recent observations of Mr. Lister (Op. cit. p. 627) on the cutaneous pigmentary
system of the frog. He points out that the pigment is contained in radiated cells, and that
the light or dark color of the frog's skin, depends upon whether the pigment is concentrated
in the centre of these cells, or diffused throughout their processes. These pigment cells are
under the control of the nervous system ; for when the nerves going to a part are divided, a
diffusion of the pigment and a dark tint of the skin, comparable to the arterial relaxation,
which takes place from the same cause, are produced. Again, when the nerves of a part
are irritated, concentration of the pigment and pallor of the skin, comparable to the contrac-
tion of the muscular fibres of the arteries, are occasioned. We have, therefore, in these ex-
periments, direct evidence of the influence exercised by the nervous system over the con-
tents of the proper cellular elements of a texture.
But this influence of the nervous system is not confined to the action which it exercises
upon the contraction of the walls of the vessels, or the movements of the pigment granules
within their cells; for various experimenters, more especially Ludwig and Bernard, have
pointed oat that by stimulating the nerves going to a gland, the amount of secretion formed
in it may be greatly increased. The glands which they have particularly operated on
are the lachrymal and salivary. In these cases we cannot help supposing that the effect
produced ia due, not merely to the influence exercised by the nerves over the calibre of the
vessels of the gland, but to their action on the proper secreting elements.
54 CONDITIONS NECBSSARY TO
may be inflammation of the eye from irritants which the paralyzed or-
bicularis palpebrarum cannot shut out or help to remove ; but neither
this nor any other injury of these nerves is comparable with the conse-
quences of the destruction of the trigeminal ; consequences which in
the rabbit are manifest, and may be very grave within a day of the de-
struction of the nerve, and may be completely destructive of the eye
within three days.*
In many of these cases it is difficult to say whether the influence on
nutrition is exercised through sensitive nerve-fibres of the cerebro-spi-
nal system, or through sympathetic (ganglionic) nerve-fibres ; and I
think it is probable that it may be exercised through either.
On the one side we have the fact that the destruction of the eye en-
sues more quickly after division of the trigeminal nerve in front of the
Gasserian ganglion, than when the division is made between the gan-
glion and the brain. This may imply that filaments derived from the
ganglion, or passing through it from the sympathetic nerve, are those
through which the influence on nutrition is exercised. And their suffi-
ciency is supported by the fact that great disturbance in the nutrition
of the eye is an ordinary consequence of the extirpation of the superior
cervical ganglion of the sympathetic, even when the trigeminal nerve is
unaffected.f
But, on the other side, we have the facts of the destruction of the
eye, when the trigeminal nerve is spoiled near its origin, the sympa-
* Some recent experiments by Snellen (De invloed der Zenuwen op de Ontstekingf Ut-
recht, 1857), would appear, indeed, to show, that after division of the trigeminal nerve, de-
struction of the eyeball may be, for a time at least, averted, by preventing all irritating
agents from coming in contact with the front of the globe. This Snellen effected by closing
the lids, and stitching the sensitive ear of the rabbit he operated on in the front of the eye.
Ten days after the operation the eyeball was clear and normal. The conclusion he draws '
is that section of the trigeminus does not of itself produce keratitis, nor affect the nutrition of
the globe. Schiff (Physiologic, part i, p. 387, 1859), has carefully repeated the experiments
of Snellen, and finds that in every case, after section of the nerve, hyperaemia of the iris and
conjunctiva, with increased secretion of conjunctival mucus, immediately occurs. The opa-
city of the cornea was, however, although never completely wanting, yet very variable in
amount and position, which variation appears to indicate that corneal opacity is not an im-
mediate and necessary consequence of neuroplastic hypereemia. It is only, however, when
this' form of hyperaemia exists, that a comparatively slight irritation can produce inflamma-
tion and destruction of the globe. Whilst the above experiments show that section of a
nerve, involving withdrawal of nervous influence, may produce but little change in the mode
of nutrition of an organ, beyond hyperaemia and the consequences resulting from it, other
experiments again illustrate the very serious mischief which may arise if a nerve be irri-
tated. Thus Samuel (Schmidt's Jahrbuch, 1859, No. 10, p. 102), by passing a galvanic
current through the Gasserian ganglion, produced immediate vascularity of the conjunctival
an abundant flow of tears, and increased sensibility of the parts, which after a time were
followed by violent inflammation, with opacity of the cornea.
f There is reason to believe that the experiments of Mageudie, on which physiologists
base the statement, tliat destruction of the eye ensues more quickly after division of the
ophthalmic division of the fifth, than when the division is made between tlie ganglion and
the brain, are either erroneous, or have been misinterpreted. For Schiff (Op. cit. p. 388),
from numerous experiments, has convinced himself that, in relation to vascular paralysis
and its consequences, there are no recognizable differences produced in the eye when the
nerve is divided in front of, or behind, the ganglion.
HEALTHY NUTRITION. 55
thetic nerve being sound (as in the case by Mr. Stanley) ; and of the
defective nutrition in consequence of injuries of the spinal cord, when
also the sympathetic centres are uninjured ; as in the cases by Sir B.
C. Brodie and Mr. Travers. For this view, also, is the occurrence of
general atrophy in consequence of diseases of the brain.
Finally, when defective nutrition follows injury of the spinal cord, it
appears to be, directly, due to the injury of the sensitive rather than
the motor nerve-fibres. Sloughing of the bladder and other parts oc-
curs, I believe, in such cases, earlier and more extensively when sensa-
tion, than when motion alone, is lost. And Mr. Curling has recorded
this case :* Two men were, at nearly the same time, taken to the
London Hospital with injury of the spine ; one had lost only the power
of motion in the lower extremities ; the other had lost both motion and
sensation ; and at the end of four months the atrophy of the lower ex-
tremities in this last was far more advanced than in the first.
None of these cases, however, enable us to say whether the influence
on nutrition is exercised through sensitive fibres of the cranio-spinal
system or through sympathetic fibres ; nor do I think this question can
be yet determined.
The last condition which I mentioned as essential to healthy nutri-
tion, is a healthy state of the part to be nourished.
This is, indeed, involved in the very idea of the assimilation which is
accomplished in the formative process, wherein the materials are sup-
posed to be made like to the structures among which they are deposited ;
for unless the type be good, the antitype cannot be.
In a part which was originally well formed, and with which the three
•conditions of nutrition already illustrated have been always present,
this fourth condition will probably be never wanting ; for the part will
not. of itself deflect from the normal state. But when any part, or any
constituent of the blood, has been injured or diseased, its unhealthy
state will interfere with its nutrition long after the immediate eff'ects of
the injury or disease have passed away. Just as, in healthy parts, the
formative process exactly assimilates the new materials to the old, so
does it in diseased parts : the new-formed blood and tissues take the
likeness of the old ones in all their peculiarities, whether normal or ab-
normal ; and hence the healthy state of the part to be nourished may be
said to be essential to the healthy process of nutrition.
The exactness of assimilation accomplished by the formative process
in healthy parts has been already, in some measure, illustrated, as pre-
serving through life certain characteristic difierences, even in the several
parts of one organ ; preserving, also, all those peculiarities of struc-
ture and of action, which form the proper features, and indicate the
temperament, of the individual.
♦ Medico-Cbir. Trans, vol. xx, p. 342.
L
56 CONDITIONS NECESSARY TO
In these, and in a thousand similar instances, the precision of assimi-
lation in the formative process is perfect and absolute, except in so far
as it admits of a very gradual alteration of the parts, in conformity
with the law of change in advancing years.
Nor is there less of exactness in the assimilation of which a part that
has been diseased is the seat. For, after any injury or disease, by
which the structure of a part is impaired, we find the altered struc-
ture,— whether an induration, a cicatrix, or any other, — as it were,
perpetuated by assimilation. It is not that an unhealthy process con-
tinues : the result is due to the process of exact assimilation operating
in a part of which the structure has been changed : the same process
which once preserved the healthy state, maintains now the diseased one.
Thus, a scar or a diseased spot may grow and assimilate as its healthy
neighbors do. The scar of the child, when once completely formed,
commonly grows as the body does, at the same rate, and according to
the same general rule ; so that a scar which the child might have said
was as long as his own fore-finger, will still be as long as his fore-
finger when he grows to be a man.
Yet, though this increase and persistence of the morbid structure be
the general and larger rule, another within it is to be remembered ;
namely, that in these structures there is usually (especially in youth) a
tendency towards the healthy state.
Hence, cicatrices, after long endurance, and even much increase, may,
as it is said, wear out ; and thickenings and indurations of the parts
may give way, and all become again pliant and elastic.
The maintenance of morbid structures is so familiar a fact, that not
only its wonder, but its significance, seem to be too much overlooked.
What we see in scars and thickenings of parts appears to be only an ex- ,
ample of a very large class of cases ; for this exactness by which the for-
mative process in a part maintains the change once produced by disease,
offers a reasonable explanation of the fact that certain diseases usually
occur only once in the same body. The poison of small-pox, or of scar-
let fever, being, for example, once inserted, soon, by multiplication or
otherwise, affects the whole of the blood ; alters its whole composition ;
the disease, in a definite form and order, pursues its course; and,
finally, the blood recovers, to all appearance, its former state. Yet it
is not as it was : for now the same material, the same variolous poison,
will not produce the same effect upon it ; and the alteration thus made
in the blood or the tissues is made once for all : for, commonly, through
all after-life the formative process assimilates, and never deviates from
the altered type, but reproduces materials exactly like those altered by
the disease ; the new ones, therefore, like the old, are incapable of al-
teration by the same poison, and the individual is safe from the danger
of infection.
So it must be, I think, with all diseases which, as a general rule, at-
tack the body only once. The most remarkable instance, perhaps, is
HEALTHY NUTRITION. 57
that of the vaccine virus. Inserted once in almost infinitely small
quantity : yet, by multiplying itself, or otherwise, affecting all the blood,
it may alter it once for all. For, unsearchable as the changes it effects
may be, inconceivably minute as the difference must be between the
blood before, and the blood after, vaccination ; yet, in some instances,
that difference is perpetuated ; in nearly all it is long retained ; by as-
similation, the altered model is precisely imitated, and all the blood
thereafter formed is insusceptible of the action of the vaccine matter.
In another set of diseases we see an opposite, yet not a contradic-
tory result. In these, a part once diseased is, more than it was before,
liable to be affected by the same disease ; and the liability to recurrence
of the disease becomes greater every time, although in the intervals be-
tween the successive attacks the part may have appeared quite healthy.
Such is the case with gout, with common inflammation of a part, as the
eye, and many others, in which people become, as they say, every year
more and more subject to the disease.
I do not pretend to determine the essential difference between the
two classes of disease in these respects, in which they are antipodal ;
but in reference to the physiology of the formative process, they both
prove the same thing, viz., that an alteration once produced in a tissue,
whether by external influence, or by morbid material in the blood, is
likely to be perpetuated by the exactness of assimilation observed in
the formative process, i. e, by the constant reproduction of parts in
every respect precisely like their immediate predecessors.
But it will be said, the rule fails in every case (and they are not rare)
in which a disease that usually occurs but once in the same body, oc-
curs twice or more ; and in every case of the second class in which lia-
bility to disease is overcome. Nay, but these are examples of the ope-
ration of that inner, yet not less certain, law, — that after a part has
been changed by disease, it tends, naturally, to regain a perfect state.
Most often the complete return is not effected ; but sometimes it is, and
the part, at length, becomes what it would have been if disease had
never changed it.
I will here refer again to what was said in the first lecture concern-
ing the blood's own assimilative power. After the vaccine and other
infectious or inoculable diseases, it is, most probably, not the tissues
alone, but the blood as much or much more than they, in which the
altered state is maintained ; and in many cases it would seem that,
whatever materials are added to the blood, the stamp once impressed
by one of these specific diseases is retained ; the blood, by its own for-
mative power, exactly assimilating to itself, its altered self, the mate-
rials derived from the food.
And this, surely, must be the explanation of many of the most in-
veterate diseases ; that they persist because of the assimilative forma-
tion of the blood. Syphilis, lepra, eczema, gout, and many more,
seem thus to be perpetuated : in some form or other, and in varying
5
58 CONDITIONS NECESSARY TO HEALTHY NUTRITION.
quantity, whether it manifests itself externally or not, the material they
depend on is still in the blood ; because the blood constantly makes it
afresh out of the materials that are added to it, let those materials be
almost what they may. The tissues once affected may (and often do),
in these cases recover ; they may have gained their right or perfect
composition ; but the blood, by assimilation, still retains its taint,
though it may have in it not one of the particles on which the taint
first passed ; and hence, after many years of seeming health, the dis-
ease may break out again from the blood, and affect a part which was
never before diseased. And this ' appears to be the natural course of
these diseases, unless the morbid material be (as we may suppose), de-
composed by some specific ; or be excreted in the gradual tendency
of the blood (like the tissues) to regain a normal state ; or finally, be,
»if I may so speak, starved by the abstraction from the food of all such
things as it can possibly be made from.*
In all these things, as in the phenomena of symmetrical disease, we
have proofs of the surpassing precision of the formative process ; a pre-
cision so exact that, as we may say, a mark once made upon a particle
of blood or tissue, is not for years effaced from its successors. And
this seems to be a truth of widest application ; and I can hardly doubt
that herein is the solution of what has been made a hindrance to the
reception of the whole truth concerning the connection of an immaterial
Mind with the brain. When the brain is said to be essential, as the
organ or instrument of the Mind in its relations with the external
world, not only to the perception of sensations, but to the subsequent
intellectual acts, and especially to the memory of things which have
been the objects of sense — it is asked, how can the brain be the organ
of memory when you suppose its substance to be ever changing ? or
how is it that your assumed nutritive change of all the particles of the
brain is not as destructive of all memory and knowledge of sensuous
things as the sudden destruction by some great injury is ? The answer
is, because of the exactness of assimilation accomplished in the forma-
tive process : the effect once produced by an impression upon the brain,
whether in perception or in intellectual act, is fixed and there retained;
because the part, be it what it may, which has been thereby changed,
is exactly represented in the part which, in the course of nutrition,
succeeds to it. Thus, in the recollection of sensuous things, the Mind
refers to a brain, in which are retained the effects, or rather, the like-
♦ The progress of the vaccine or variolous infection of the blootl shows us that a permanent
morbid condition of that fluid is established by the action of these specific poisons upon it.
And ahhough this condition may, so far at least as it protects the individual from any further
attack of the same disease, be regarded as exercising a beneficial influence upon the economy,
yet it is not the less to be looked upon as a morbid state. In forming an estimate of the per*
sistent changes produced in the blood by these and similar infectious diseases, we must not
lose sight of the influence which the tissues, themselves altered by the inoculation, exeicise
upon the blood. They will necessarily react upon it, so as to assist materially in preserving
a permanent morbid, though beneflcial condition.
THE FORMATIVE PROCESS. 59
nesses of changes that past impressions and intellectual acts had made.
As, in some way passing far our knowledge, the Mind perceived, and
took cognizance of the change made by the first impression of an ob-
ject, acting through the sense organs on the brain ; so afterwards it
perceives and recognizes the likeness of that change in the parts in-
serted in the process of nutrition.
Yet here also the tendency to revert to the former condition or to
change with advancing years may interfere. The impress may be
gradually lost Or superseded, and the Mind in its own immortal nature
unchanged, and immutable by anything of earth, no longer finds in the
brain the traces of the past.
LECTURE III.
THE FORMATIVE PROCESS : GROWTH.
Having now considered the sources of the impairment to which the
completely formed blood and tissues are prone, and the chief conditions
necessary for the perfection of the formative process, by which, not-
withstanding this impairment, they are maintained almost unchanged,
I propose to speak of the process itself.
You may remember that I referred the impairment, or wear and tear,
of the body to two principal sources — namely, the deterioration which
every part suffers in the exercise of its function ; and the natural de-
generation or death to which every part is subject after a certain pe-
riod of existence, independently of the death or degeneration of the
whole body, and in some measure, independently of the exercise of
function.
The first question, therefore, in the consideration of the nutritive
process, may be, — what becomes of the old particle, the one for the re-
placement of which the process of formation is required ? In answer,
we must, probably, draw a distinction, though we can hardly define it,
between the parts which die, and those which only degenerate, when
they have finished their course. Those which die are cast out entire :
those which degenerate are disintegrated or dissolved, and absorbed.
We seem to have a good example of this difference in the fangs of the
two sets of teeth. Those of the deciduous ones degenerate, are trans-
formed so as to become soluble and are absorbed ; those of what are
called permanent — more properly those of teeth which are not to be
succeeded by others, die, and are cast out entire. And we may proba-
bly hold it as generally true, that, as Mr. Hunter was aware, living parts
&lone are absorbed in the tissues ; dead parts, it is most probable, how-
ever small, are usually separated and cast out ; and, as the phenomena
60 THE FORMATIVE PROCESS.
of Decrosis show, this must be accomplished, not by the absorption of
the dead parts themselves, or their borders, but by the absorption or
retirement of the adjacent borders or surfaces of the living parts.
External, merely integumental, parts appear thus to die and to be
cast out entire from the body ; but we have no certain knowledge of
the changes they may undergo before they die. And with regard to
the changes which take place in the degeneration that precedes absorp-
tion of the old particles, we have again but little knowledge. Chemis-
try has, indeed, revealed much concerning the final disposal of the old
materials ; finding their elements in the excretions ; and proving that
the process is one of descent towards simplicity of organic chemical
composition ; one of approximation towards inorganic character ; and,
perhaps always, one accomplished by the agency of oxygen. It has,
also, we may safely believe, found in the muscles some of the substances
into which the natural constituents of the tissues are transformed, be-
fore they assume the composition in which they are finally excreted.
Krcatine and kreatinine are, most probably, examples of such transi-
tional compounds, intermediate between some of the proper constituents
of muscle, and urea or uric acid. And I think that the frequency with
which fatty matter is found in degenerate parts is an indication that it
is a usual product of similar transformation preparatory to absorp-
tion, and to the more complete combination with oxygen in the forma-
tion of carbonic acid and water for excretion. However, while we have
so little knowledge of these intermediate or transitional substances, we
can only hold it as generally probable, that the components of the de-
generate and out-worn tissues pass through a series of chemical trans-
formations, which begin in their natural degeneration before absorp-
tion, and are continued during and after absorption till they are com-
pleted by the oxidation in the blood which brings the materials to the
state appropriate for excretion.
With regard to the formative portion of the process — that by which
the old particle, however disposed of, is to be replaced — it is in many
cases a process of development ; a renewal, for each particle, of the
process which was in nearly simultaneous operation for the whole mass
in the original development of the tissue. There can be little doubt
that such is the case in the hair, the teeth, the epidermis, and all the
tissues which, from being situated on a free surface, we can watch ; in
all these the process of repair or replacement is efi*ected through the
development of new parts. With regard to the more internal parts, as
the muscles, their position prevents us from obtaining so satisfactory a
view of the nature of the formative process which goes on in them. It
is probable, however, that there is not such a bodily replacement as
in the structures more superficially placed, but that the nutritive
changes partake more of the molecular character, one particle being
replaced by another, whilst, as it were, the original skeleton, or frame-
work, of the texture, is preserved. In all the parts, I think, which are
THE FORMATIVE PROCESS. 61
the seats of active nutrition, nuclei or cytoblasts exist. These nuclei
(such as are seen so abundantly in strong, active muscles) are not the
loitering impotent remnants of the embryonic tissue, but apparatus of
power for new formation. Their abundance is, I think, directly pro-
portionate to the activity of growth. They are always abundant in the
foetal tissues, and those of the young animal ; so they are in many quickly
growing tissues ; and they are more plentiful in the muscles and the brain
than, so far as I know, any other non-secreting tissue of the adult.
And I think I may add that their disappearance from a part in which
they usually exist is a sure accompaniment and sign of degeneration.
A subject of very interesting inquiry is involved in the consideration
of the way in which parts repeat themselves in their nutrition, so that
the structure which succeeds is constructed after the plan of that which
preceded it.
Take the case of the blood. The new blood-corpuscles that are
being constantly formed for the renovation of the blood, are not de-
veloped from germs given off from the old ones ; neither are they formed
by any assimilative force exercised by the old ones. By watching the
stages of their construction we may see that the development of each
is an independent repetition of the process by which the first were
formed. And so with the successive developments of ova and epithelial
cells, and many others; each, is developed independently of the rest,
and each repeats the changes through which its predecessors passed.
Let it then be observed that each new elementary structure is made
in successive stages, like what the old one was, not like what it is ; as
we see in the young hair following the course of the old one, or as the
child IS made like, not what his father is now, but what he was at his
age. The new particle is, therefore, not made after a present model.
If, now, we turn from the consideration of the method of the forma-
tive process in the maintenance of the tissues, and from that of the condi-
tions under which it is exercised, to inquire into the nature of the forces
which actuate it ; if we try to answer why any structure just new-formed
has assumed nearly the same form as the old structure had which it
replaces ; we may find suggestions for an answer in the facts last men-
tioned. Among these facts we find (1), as detailed in p. 55, that a
structure already formed exercises a certain assimilative influence on
organic materials brought into contact or near proximity with it ; and
(2), that in many cases, as cited above, and yet more clearly in in-
stances of repair and reproduction of injured and lost parts, the re-
placing structures are formed entirely anew, and independently of this
influence. In these cases no model structure is present, to which the
new-forming one may be assimilated ; the new structure seems as if its
own inherent properties had determined the form that it should take.
Resting on the first class of facts, it seems to some a suflScient expla-
nation of the process of maintenance to say, that each structure in the
body has the power of taking from the blood, by a kind of elective
I
62 THE FORMATIVE PROCESS.
V
affinity, certain appropriate materials, and of so influencing them that
they assimilate themselves to it ; i. e. that they adopt or receive its
form and properties, and incorporate themselves with it.
Now, without doubt, the existence of such a selective power is justly
assumed, and we may, by reference to it, express correctly a part of
the processes by which the maintenance of the body is accomplished.
Still it is, I think, clear that it is not sufficient for the maintenance of
the body in its perfection ; for, in the explanation of all the facts of
the second class cited above, a theory of maintenance of the tissues by
assimilation is inapplicable — not merely insufficient, but inapplicable ;
for a postulate of this theory is the existence of a present model or
germ for the construction of the forming part ; and in all these cases
no such germ or model can be found. Therefore, finding in these cases
that the formative process is accomplished in the maintenance of certain
parts, without assimilation, we may assume, I think, that even when
this condition is present, it is only as an auxiliary of some more con-
stant and sufijcient force.
Of this force, by whatever name we designate it, whether as the for-
mative, or the plastic, or more explicitly, as the force by which or-
ganic matter, in appropriate conditions, is shaped and arranged into
organic structure ; of this force, and of those that co-operate with it,
we can, I think, only apprehend that they are, in the completed organ-
ism, the same with those which actuated the formation of the original
tissues in the development of the germ, and of the embryo. As we have
seen that the new formation of elemental structures in the maintenance
of tissues is a repetition of the process observed in their first develop-
ment, so we may assume that the forces operative are the same in both
processes.*
Thus then, for explanation of the maintenance of tissues by the con-
stant formation of nearly similar elemental structures, we are referred
back to the history of their first formation ; and we might be content
to rest in the belief that the mystery of the development of a germ is
wholly inscrutable. We can discern in its method only this : that the
materials of which the impregnated germ first consists, and all that it
* Concerning the very nature of such forces and their correlations, I must refer to the
admirable essays of Mr. Grove (The Correlation of Physical Forces), and Dr. Carpenter (On
the Mutual Relations of the Vital and the Physical Forces). '* In speaking of forces as pos-
sessing an absolute existence, it is not intended," says Dr. Carpenter, " on the one hand, to
imply that they are anything else than 'affections of matter;' nor, on the other, to regard
them in any other light than as the direct operation of the Primal All-sustaining Cause.
We can form no conception of matter except as possesBing properties which, when in action,
give rise to powers or forces ; whilst, on the other hand, we cannot think of forces, except as
operating through some form of matter, of whose properties they are the manifestation. The
existence of matter, and the action of the forces to which the material phenomena (whether
physical or vital) are attributable, are alike the expressions of the Divine Will ; and our aim
must be limited to the discovery of the plan, according to which it has pleased the Creator
to develop and maintain the existing condition of the universe we inhabit." — General Phy-
siology^ p. 36.
THE FORMATIVE PROCESS. 63
appropriates, are developed according to the same method as was ob-
served in its progenitors, so that at every stage it is like what they were
at the same stage. It is in conformity with the same law of formation
according to the example of progenitors, that when the general develop-
ment of the body is completed, each of its parts is still maintained or
gradually changed. In each period of life, the offspring resembles the
parents at the corresponding periods of their life ; and, especially, in
those degenerative changes which ensue in old age, we can discern no
other method, or law, than still the same : that the parental form, and
properties, and life, are imitated or reproduced in the offspring.
Now, can we trace anything further back than this fact ? Probably
not ; but we may express it in other terms, which may be more con-
veniently used in our further inquiries, by saying that each germ de-
rives from its parents such material properties that, being placed in
the conditions necessary for the operation of the formative and other
vital forces, it will imitate in.all the phases of the life of each of its
parts, the changes through which the corresponding parts passed in the
parents. It is convenient, and probably right, while we assumie the
operation of a formative force, still to refer the method of its peculiar
manifestations to the material properties of the substances in which it
acts. In the case before us, we may accordingly assume, that peculiar
and typical properties are transmitted from its parents to the mate-
rials of each impregnated germ ; that these determine, under the ope-
ration of the formative force, the construction of corresponding pecu-
Uar and typical forms ; that they are also communicated to whatever
materials capable of organization are brought within the sphere of the
developing germ, so that these also determine the same, or some defi-
nitely related, method of construction ; and that thenceforward,
throughout life, by similar communication or induction of specific pro-
perties in the forming blood or other nutritive fluid, the same method
of formation is maintained in all the tissues.
Unless we thus assume a dependence of form upon composition, of
organic structure upon organic constitution, I think we cannot under-
stand, or even clearly speak of, many of the deflections from the nor-
mal formative process which are due to injury or disease : deflections
which, as we have seen, are maintained in the blood and tissues, and
the tendency to which is, in hereditary diseases, transmitted from pa-
rent to offspring with the other properties of the germ.
The sum, then, of the hypothesis concerning the formative processes
in the maintenance of the tissues is as follows : It is assumed, first,
that a certain vital formative, or plastic, or constructing force, is in
constant operation ; 2dly, that the forms -assumed, under its influence,
depend primarily, and in greatest measure, on the specific composition
and other properties of the organizable materials taken from the blood ;
and, 3dly, that these properties, transmitted in the first instance from
the parent to the germ, are thenceforward communicated to the nutri-
i
64 GROWTH.
tive materials, subject, however, to certain progressive changes cor-
responding to the development and degenerations of the several tis-
sues.*
It is assumed further that the taking of materials from the blood, by
each part for its own maintenance, depends, as to quality, on certain
definite relations, or "organic affinities" between the blood and the
part ; and as to quantity, on the waste of the part. As to the influ-
ence of an assimilative force, exercised by the tissues already formed,
upon the nutritive materials placed in them, it is probable that this is
not a plastic or constructive force, but chiefly such a one as, like the
assumed catalytic force, or that of a ferment, affects first the composi-
tion of the materials not yet organized, and thus indirectly, affects the
form that they assume in organizing.
I fear I may have seemed to have engaged in a very useless discus-
sion, and to have been talking of words more than of things ; but the
charge will not be made by one who knows the utility of being clear in
the expressions used for the groundwork of teaching ; or who will con-
sider the importance in pathology of the principle that specific organic
structures correspond with, and are determined by, specific organic
compositions.
I propose now to consider, but as yet only generally, the second me-
thod of the formative process. Growth, in health and in disease.
It consists in the increase of a part, or of the whole body, by addi-
tion of new material like that already existing. The essential charac-
ters of each organ or tissue are maintained, but its quantity is increased,
and thus it is enabled to discharge more of its usual function.
For a general expression of the course of events, we may say that
the development and the growth of the body go on together till all the
natural structures are attained ; and that then development ceases, and
growth goes on alone, till the full stature and the full proportion of
each part to the rest are gained. But this is only generally true ; for
we cannot say that all development ceases at a determinate period,
since some organs may go on to be developed when many others are
complete. Neither can we assign the period of terminated growth,
since not only is the period, even stated generally, very various in
diffbrent persons, but some parts, unless placed in unfavorable condi-
tions of disease, continue growing to the latest period of life. M. Bizot
and Dr. Clendinning have proved, of the heart and arteries, that their
average size regularly increases, though with a decreasing ratio of in-
crease, from childhood to old age, provided only the old age be a lusty
one.f And this is a real growth ; for the heart not only enlarges with ad-
* This assimilating force is probably especially exercised by organized structures, which
may present those simple forms which we recognize as nuclei, or they may possess the
more complicated form of the cell.
f Croonian Lectures by Dr. Clendinning, Medical Gazette for 1837-8, vol. xxii, p. 450.
HYPERTROPHY. 65
vancing years, but its weight augments, and the thickness of its walls
increases ; so that we may believe it acquires power in the same pro-
portion as it acquires bulk, — the more readily, since the increased
power ie necessary for the increasing diflSculties put in the way of the
circulation by the increasing rigidity of the parts.
It may be that the. same is true of some other parts. This certainly
is true, that any part, after it has attained its ordinary dimensions, ac-
cording to the time of life, may grow larger if it be tnore exercised ;
in other words, every part has throughout life, the power of growing,
according to its particular needs, in correspondence with the degree in
which its function is discharged.
Now when such growth as this is the result of the natural, though
almost excessive exercise of a part (as of the limbs, for example, during
hard work), we regard it only as an indication of health, and its result
is admitted to be a desirable accession of strength. But when such
growth in one part is the consequence of disease in another, it is com-
monly described as a disease ; it bears the alarming name of Hyper-
trophy, and it comes to be a subject of consideration in Morbid
Anatomy.
But in both these cases the process of growth is the same, and is
according to the same rules ; and the tendency of the process of genu-
ine hypertrophy in disease, like that of healthy growth in active exer-
cise, is always conservative. I say genuine hypertrophy, meaning,
under that term, to include only the cases in which the enlargement of
a part is effected with development or increase of its natural tissue,
with proportional retention of its natural form, and with increase of
power. To include all enlargements under the name of hypertrophy
b too apt to lead to misunderstanding.
The rule, then, concerning hypertrophy is, that so long as all con-
ditions remain the same, each part of the body, after the attainment
of the average size, merely retains its state, or at most, grows at a
certain determinate slow rate ; but when the conditions alter, so that
a part is more than usually exercised in its oflSce, then it manifests a
power of renewing or accelerating its growth. It is as if each healthy
part had a reserve power of growth and development, which it puts
forth in the time of emergency.
And the converse is equally true. When a part is less than usually
exercised, it suffers atrophy, so that the rule may be that each part
nourishes itself according to the amount of function which it dis-
charges.
We may constantly see this rule in many more examples than I need
refer to. The simplest case that can be cited is that of the epidermis.
In its original formation, even before it has come into relation with the
external world, it is formed on the several parts of the body, — take for
example the back and the palm of the hand, — in different quantity and
kind, adapted to the several degrees in which the cutis it is to protect
66 HYPERTROPHY.
will be exposed to pressure, friction, and the influence of other external
forces. And not only are its original quantity and construction on these
parts different, but its rate of growth is so ; for though the back of the
hand loses comparatively little by friction or otherwise, yet its epider-
mis does not grow thick ; and though the palm loses more, yet its epi-
dermis does not grow thin. So, then, both in original construction and
in rate of formation, the epidermis is thus adapted to the amount of
function it has to discharge, that is, to the amount of protection it has
to afford. But suppose now that by some new handicraft, the amount
of exercise of the epidermis is increased, its rate of waste is increased
in the same proportion, yet it does not grow thin ; nay, it grows
thicker, till it is completely adapted to protect the cutis from the
greater sources of injury to which it is now exposed ; it puts forth, as
it were, a reserve power, which is enough not only to repair all amount
of waste within certain limits, but further than this, to increase the
quantity of the tissue to the amount required for the discharge of its
increased functions. ^
What we can see in this case of the cuticle, we may be sure of for
other tissues : for example, in a muscle ; as in a heart, when, by dis-
ease of the valves, an obstacle is put in the way of the circulating
blood, and the heart, or one of its cavities, acts with additional force
to drive it on. But, as we know, the more of action in a muscle, the
more the consumption of the tissue, so we might now expect a diminu-
tion of the heart. On the contrary, it enlarges ; it is hypertrophied ;
the formative process not only meets the immediate exigencies of the
increased consumption of muscular tissue, but produces enough to act
with the additional power required by the increased diflSculty of the
circulation.
Such are the effects of growth in examples of hypertrophy. But,
to meet the increasing diflSculties of these and the like cases, a part
may do more than grow ; it may develop itself ; it may acquire new
structures, or it may improve those of which it is already composed,
so as to become fit for higher functions and the exercise of greater
power. For example, in the most ordinary hypertrophy of the heart,
the muscular tissue is developed to more robustness : its fibres become
not only larger, or more numerous, but firmer, more highly colored,
and stronger. In the pregnant uterus, such fibres are formed as are
not seen in the unimpregnated state ; they are, indeed, not a new kind
of fibre, but they are so different in size and shape, and so much more
powerful than those which existed before, that we may justly speak of
them as developed. And this change by development, which in preg-
nancy is natural, is often imitated in disease, when, by the growth of
fibrous tumors in it. the uterus attains the size, the structure, and even
the full capacity of action, of the pregnant organ. In several of such
cases the uterus has at length imitated the course of labor, and de-
livered itself of the tumor by its contractile power.
HYPERTROPHY. 67
A similar change, by development and growth of muscular fibres,
may occur in the gall-bladder, the ureter, and, probably, in any other
part that has the smooth muscular fibro-cells.
We have an example of development of a secreting structure in the
bursa, which, as Hunter displayed it, is produced under a corn. The
corn itself is the result of a kind of hypertrophy, tending to shield the
cutis from unnatural pressure ; but, itself becoming a source of greater
trouble than that against which it was directed, it gives rise to the de-
velopment of a bursa beneath it, which may, for a time, more effec-
tually protect the joint beneath, by diffusing the pressure over a wider
extent of surface.
All these are examples that this hypertrophy, as we call it, though it
happens in circumstances of disease, is yet in general, so far as itself is
concerned, a process of full and vigorous health, serving to remedy, or
keep back, the ill effects that would ensue from disease in some other
part. It is, in a less degree than the repair of a fracture or other me-
chanical injury, an instance of the truth that we are provided for acci-
dents and emergencies ; framed not merely to live in peace and same-
ness, but to bear disturbances ;' to meet, and balance, and resist them,
and, sometimes at least, to counteract them.
The amplified healthiness of the formative process exercised in hy
pertrophy is testified by its requiring a full measure of all the condi-
tions of ordinary nutrition. It needs healthy and appropriate blood :
and one of the most interesting studies is to watch the hindering influ-
ence of disease on the occurrence and progress of hypertrophy, espe-
cially that of the heart. In some of these cases, to which I shall have
again to refer, death seems clearly to be the consequence of impairment
of the blood, which can no longer maintain in the heart the exceeding
growth required for its increased functions.
We find, moreover, very constantly,' that, as if to insure sufficient
blood to the grown or growing part, the main arteries and veins be-
longing to it are enlarged. This is usually well shown in the en-
larged coronary arteries of the hypertrophied heart ; an instance analo-
gous to the enlargement of the arteries of the pregnant uterus, and the
growing antlers of the deer, and many others. According to all ana-
logy, we must consider this increase of the bloodvessels to be secon-
dary. As in the embryo, parts form without vessels, till, for their fur-
ther nutritioa as their structure becomes more complex, the passage of
blood into their interior becomes necessary, so we may be sure, it is
here. It may seem, indeed, strange that a part should have the power
of determining in some measure the rate at which blood shall flow into
it and through it ; but so it is, and nearly all examples of hypertrophy
are examples of the fact ; though, as I shall presently have to mention,
there are instances in which hypertrophy is the consequence, not the
caase, or precedent, of increased supply of blood.
With the increased supply of blood proportioned to the increased
i
68 HYPERTROPHY.
nutrition of the growing part, the nerves may also increase ; as in
the pregnant uterus and the hypertrophied heart. So, at least, I be-
lieve ; but probably I need not apologize for evading the discussion of
this matter.
The conditions which give rise to hypertrophy are chiefly or only
three, namely :
1. The increased exercise of a part in its healthy functions.
2. An increased accumulation in the blood of the particular mate-
rials which a part appropriates to its nutrition or in secretion.
8. An increased afflux of healthy blood.
Of hypertrophy as the consequence of the increased exercise of a
part, I have already spoken generally ; and we need no better exam-
ples of it than the muscles of a strong man's arm, fitted for the very
exercise in which they acquired bulk and power, or the great robust
heart of a man who has suffered some .disease producing obstacle to the
movement of the blood. Both alike are the results of vigorous healthy
growth, brought about by exercise of the part in its proper function.
In a former lecture (p. 40) I spoke of the increased growth of the
kidney, and of the adipose and other tissues, when the chief constitu-
ents of their structures exist in excess in the blood. To these I may
refer again as examples of the second kind of hypertrophy. And I
just now mentioned, that although in most cases an increased circula-
tion of blood is the consequence of hypertrophy, yet there are cases in
which the course of events is inverted. The increased flow of healthy
blood through a part, if it be not interfered with by local disease, will
give rise to hypertrophy of the part, or at least of some of its tissues.
This fact is shown very well in a specimen (No. 6) in the Museum,
which Mr. Hunter describes as " a sore which had continued inflamed
a long time, where the increased action had made the hair grow." The
integuments, for about an inch 'round the ulcer, where probably there
was simply increased supply of blood, are covered with thick-set, long,
and rather coarse, dark hairs : while on the more distant parts of the
integuments, the hair is paler, more slender, and more widely scat-
tered.
Similar examples of overgrowth of the hair through increased supply
of blood, assisted probably by more than usual external warmth and
moisture, are frequently seen near the ends of stumps which have re-
mained long inflamed, and about old diseased joints; not, indeed, at the
very seat of inflammation, but at some little distance from it, where
the parts share the increased supply of blood, but not the disease of in-
flammation. Such cases are often observed on limbs in which frac-
tures have occurred. I remember one very striking case in the thigh
of a child about five years old. The femur had been fractured near
the middle: the case did not proceed favorably, and union was not
accomplished without much distortion. When I saw (he child, I was
at once struck with a dark appearance on the thigh : it was all covered
HYPERTROPHY. 69
vith dark hair like that of a strong coarse-skinned man ; yet on the
rest of the body, the hair had all the fineness and softness ^rhich are
proper to it in early life.
Similar facts are presented by some cases of transplantation. When
the spur of a cock, for example, is transplanted from the leg to the
comb, which abounds in blood, its growth is marvellously augmented,
and it increases to a long, strange-looking mass of horny matter, such as
IS shown in two preparations in the Museum of the College. In one
(54) the spur has grown in a spiral fashion till it is six inches long ; in
the other (52) it is like a horn curved forwards and downwards, and its
end needed to be often cut^ to enable the bird to bring his beak to the
ground in feeding, and to prevent injurious pressure on the side of the
neck.
It is worth observing, that these excessive growths have taken place
on the combs without any corresponding diminution in the growth of
the spurs in their proper places. The legs of these cocks are amply
spurred, though the spur reproduced is not so long as that which had
not been interfered with. In one instance, moreover (No. 53), there
is an excessive production of the horny scales upon the legs, while the
homy spur was also excessively growing on the comb.
I shall have occasion presently to mention cases which make it very
probable that the more complex and vascular tissues, such as the mus-
cles, integuments and bones of a limb, can be thus hypertrophied by
excess of blood. I will now only suggest the probability that the cases
of congenital or spontaneous hypertrophy of a hand or a foot, or of one
or more fingers, have their origin in some excessive formation of the
vessels, permitting the blood to flow more abundantly through the part.
An enlargement of the radial artery has been observed by Dr. John
Reid* in a case of such hypertrophy of the thumb and fore-finger ; but
there is no evidence to determine whether in this case the enlargement
of the artery was previous or subsequent to the excessive growth of the
part.
Whatever be the case in these instances of enlargement, the fact,
which the others show, that well-organized tissue, like hair and horn,
is produced in consequence of simply increased supply of blood, stands
in interesting contrast with the phenomena of inflammation, where no
tissue, or only the most lowly organized, is ever formed. No fact can
better show how far the mere enlargement of the bloodvessels is from
constituting the essential part of inflammation.
Through cases of hypertrophy, such as these, the transition is made
to those which, though they appear to consist in simple increase of the
natural texture of parts, we yet must regard as morbid, inasmuch as
they are frequently productive of inconvenience to the individual, and
* Lond. and Edinb. Monthly Journ. of Medical Science, 1843, and in a collection by Mr.
Curling in the Med.-Chir. Trans., vol. xxviii.
70 HYPERTROPHY
we do not know that they are adapted to any exigency of the economy.
Such are the simple enlargements of the thyroid, thymus, and prostate
glands, of the spleen, and tonsils : such too are some examples of mu-
cous polypi, and of cutaneous outgrowths and warty growths of the
skin. These all present an increase of natural textures ; and they may
be instances of purposive growth, adapted and conservative : but till \t
is more manifest that they are so, we must be content, I think, to re-
gard them as occupying a kind of middle ground between the genuine
hypertrophies of which I have been speaking, and the thoroughly mor-
bid outgrowths of which a part of the class of tumors is composed.
On another side, there are cases intermediate between hypertro-
phies and the results of inflammation, and no line of distinction can be
drawn among them, if we rely on their anatomical characters alone ;
for, in the lowest degrees of inflammation, the exuded material may be
organized into a very near likeness to the natural tissues, and may thus
seem to increase their quantity. If these inflammatory hypertrophies,
as they have been called, can be distinguished from true ones, it is only
by their being unattended with increase of functional power, or fitness
for the part's relations.
LECTURE IV.
HYPERTROPHY.
Let me now further illustrate the general physiology of Hypertrophy,
by adducing some of the specimens in the Museum which exhibit it in
the principal tissues.
The first specimen in the Pathological division of the Museum is a
urinary bladder hypertrophied in consequence of stricture of the ure-
thra. It affords an admirable instance of genuine unmixed hypertro-
phy ; for every part of the bladder is grown large ; it is not contracted
as if it had been morbidly irritable ; and its mucous membrane, without
induration or any similar morbid change, is increased, apparently by
simple growth, to a thickness proportionate to that of the muscular
coat.
I adduce this especially as an example of hypertrophy of muscular
tissue, concerning which, instead of adding to what was said in the
last lecture, I will quote Mr. Hunter's account. Referring, perhaps,
to this very specimen, he says, in a passage which I have inserted in
the Catalogue :* " The bladder, in such cases [of obstruction to the
passage of urine], having more to do than common, is almost in a con-
stant state of irritation and action ; by which, according to a property
* Vol. i, p. 3 ; and Hunter's Works, ii, 299.
OF MUSCLE. 71
in all muscles, it becomes stronger and stronger in its muscular coat ;
and I suspect that this disposition to become stronger from repeated ac-
tion is greater in the involuntary muscles than the voluntary ; and the
reason why it should be iSO is, I think, very evident : for, in the invo-
luntary muscles, the power should be in all cases capable of overcoming
the resistance, as the power is always performing some natural and ne-
cessary action ; for whenever a disease produces an uncommon resis-
tance in the involuntary parts, if the power is not proportionally in-
creased, the disease becomes very formidable ; whereas in the voluntary
muscles there is not that necessity, because the will can stop whenever
the muscles cannot follow ; and if the will is so diseased as not to stop,
the power in voluntary muscles should not increase in proportion."
Nothing, surely, could more appositely, or more exactly, express the
truth, concerning hypertrophy of muscle : and it may be observed, from
what he says in a note, that Mr. Hunter appears to have been the first
who rightly apprehended the nature of this growth of the bladder. He
says, ^* This appearance was long supposed to have arisen from a disease
of this viscus ; but, upon examination, I found that the muscular parts
were sound and distinct, that they were only increased in bulk in porpor-
tion to the power they had to exert, and that it was not a consequence of
inflammation, for in that case parts are blended into one distinct mass."
What this specimen shows in the urinary bladder is an example of
the change which ensues in all involuntary muscles under the same cir-
cumstances. They all grow and acquire strength adapted to the new
and extraordinary emergencies of their case. Thus, the oesophagus,
the stomach, the intestinal canal, as often as any portion is the seat of
stricture, display hypertrophy of the muscular coat above the stricture.
The enormous enlargements of the intestinal canal, which gradually
ensue above nearly impassable strictures of the rectum, are not mere
dilatations, but growths of the intestinal walls ; the muscular coat aug-
menting in power, to overcome, if it may, the increased hindrance to
the propulsion of the contents, and even the glands and other textures
of the mucous membrane simultaneously increasing.
In a great majority of cases, the hypertrophy of muscles, whether
voluntary or involuntary, is the consequence of an increased obstacle
to their ordinary action. Against this obstacle they exert extraordi-
nary force, and this induces, indirectly, extraordinary formation of
their tissue. Frequent action of muscles, unless it be also forcible,
does not produce hypertrophy. As Dr. Humphry* says, the heart,
though it may act with unusual frequency for years, yet does not in
these cases grow larger ; and the muscles of the hands are not gene-
rally so large in mechanics who use great celerity of action as in those
who work with great force. But action of muscles, if it be at once fre-
quent and forcible, may produce hypertrophy, even though the action
♦ Lectares on Surgery, in Prov. Med. and Surg. Journal j Reprint, p. 108.
72
HYPERTROPHY
be unhealthy. This appears to be the case with the bladders of some
children, who suffer with fi^equent and very painful micturition, and
all the signs of calculus, but in whom no calculus exists. The bladder
in such children is found, after death, exceedingly hypertrophied, and
there may be no other disease whatever of the urinary organs. Dr.
Golding Bird has shown that phymosis, by obstructing the free exit of
urine, may give rise to these signs and to extreme hypertrophy of the
bladder ; but in some cases it appears certain that hypertrophy may
occur without either phymosis, calculus, stricture, or any similar obstruc-
tion. It was so in a case illustrated in the Museum of St. Bartholo-
mew's (xxvii, 14), in a child four years old, who had suffered intensely
with signs of stone in the bladder, but in whom no stone existed ; no dis-
ease of the urinary organs could be found, except this hypertrophy of
the muscular coat of the bladder. An exactly similar case was under
Mr. Stanley's care, in which, after exceeding irritability of the bladder,
the enlargement of its muscular coat appeared the only change.
In such cases, the too frequent and strong action of the bladder,
though irritable and unhealthy, seems alone to give rise to hypertro-
phy of the fibres. It is, however, possible that the change may be due
to narrowing of the urethra by muscular action. If, for example, the
compressors of the urethra, instead of relaxing when the muscular coat
of the bladder and the abdominal muscles are contracting, were to con-
tract with them, the obstacle they would produce in the urethra would
soon engender hypertrophy of the bladder.
Hunter, whose ingenuity was ever tempting on his intellect and in-
dustry, asked himself whether the hypertrophy of the heart were ac-
complished by the addition of new fibres, or by the enlargement of
those that already exist, for it will be well to bear in mind that hyper-
trophy may manifest itself, not only in the heart, but in other textures,
in one, or other, of these two modes, either by a simple or numerical
increase. This question could hardly be determined without more mi-
croscopic aid than Hunter had at his command. And even at this
present time, with the command of much finer means of investigation,
there appear to be difiiculties in the way of answering this question ;
for whilst we have, on the one hand, Harting,* Kblliker,t and Hepp^
asserting that in the growth of striped muscles there is no numerical
increase ; on the other, Budge,§ G. Schmidt,|| and Weissman^ positively
state that new muscular fibres do arise during growth.
Hypertrophy of bone presents itself in many interesting cases.
It is usually a secondary process, ensuing in consequence of change
in a part with which some bone is intimately connected. Just as in
their natural development and growth, the bones of the skull are formed
* Recherches Microm^triques, 1845, p. 62.
X Canstatt, 1853, p. 43.
i Vircbow's Archiv, 1859, vol. 18.
t Micros. Anatomie, ii, 255.
$ Deutsche Klinik. April 17, 1858.
f Zeitsch. f. Rat. Med. vol. x, p. 263.
OF BONES. 73
in adaptation to the brain, and those of the limbs are framed to a fitness
for the action of the muscles ; so, in disease, they submit in their nutri-
tion to adapt themselves to the more active parts. Thus, the skull en-
larges when its contents do ; and the bones of the limbs strengthen
themselves as the muscles inserted on them become stronger and more
active ; and they do this in adaptation to the force of the muscles, and
not merely because of the movements they are subject to : for no extent
or force of passive movement would prevent the bones of a limb whose
muscles are paralyzed from suffering atro{)hy.
In the skull, if in any organ, we might speak of two forms of hyper-
trophy, eccentric and concentric. When the cranial contents are en-
larged, the skull is hypertrophied with corresponding augmentation of
its area ; and when the cranial contents are diminished, the skull (at
least in many cases) is also hypertrophied, but with concentric growth,
and diminution of its capacity.
The first, or eccentric form, is usually the consequence of hydroce-
phalus ; wherein, as the fluid collects and distends the dura mater, so
the skull grows ; still, as it were, striving to attain its purpose, and
form a complete envelope for the expanding brain.
The process of enlargement in these cases is often one of simple
growth, and that, indeed, to a less extent than it may seem at first
sight : for it is very rarely that the due thickness of the skull is attained
while its bones are engaged in the extension of their superficial area.
Hence, the weight of a hydrocephalic skull is not much, if at all,
greater than that of a healthy one ; a large parietal bone,* measuring
nine inches diagonally, weighs only four ounces, while the weight of an
ordinary parietal bone is about three ounces.
It is interesting to observe, in some of these cases, the symmetrical
placing of the Wormian bones, by which the extent of the skull is in
a measure made up. They show how the formative process, though
thus thrown into straits and difiiculties, yet conforms, both in growth
and development, with the law of symmetry.
It would be yet more interesting if we could certainly trace here
something of conformity with the law of unity of organic type, in the
mode of insertion of these Wormian tntercalary bones, when compared
with those of other animals. It cannot be certainly done ; and yet, in
some of these specimens, there appears (as if in accordance with that law)
a tendency to the formation of the Wormian bones at the posterior part
of the sagittal suture more than in any other part, as if in imitation of
the interparietal bones of Rodents. And in the very rare specimenf
sketched in the diagram (Fig. 3), in the midst of great confusion of the
other bones, we find a remarkable bony arch, extending from between
the two frontals to the occipital bone ; occupying, therefore, the place
* No. 2 in the College Museum. f No. 3487 in the same Museum.
74 HYPERTROPHT
of a ]arge interparietal bone, and reminding ns of some of the monkeys,
e.g. Gebus and Jacchns. We hare a somewhat corroborative specimien
in the inmmenee hydroce-
^'S- S- phalic ekuU of the Bkeleton
from Mr. Liston's Muaeam
(No. 3489), in which the in-
terparietal Wormian bones
are larger than any others.
The hypertrophy of the
skull, which may be called
concentric, is that which
attends atrophy with shrink-
ing of the brain, or perhaps,
any disease of the brain in
which there is diminution of
its bulk. In such a case it usually happens, as waa first shown by Dr.
Sims,* that the skull becomes very thick.
All the specimens which I have examined show, however, that in
these cases the thickening of the skull is not in itself a morbid process ;
it manifests" definite purpose ; is usually effected by healthy growth ;
and observes the rules followed in the natural formation of the skull.
Thos, as in its first formation, the skull adapts itself to the form and
size of the brain, or rather, of its membranes ; only now it does so
without representing on its exterior the change which has taken place
within. The thickening of the skull is effected by the gradual remodel-
ling of the inner table and diploe of the bones of the vault ; so that,
although the exterior of the skull may retain its natural form and size,
the inner table grows more and more inwards, as if sinking towards the
retiring and shrinking brain ; not thickening, but simply removing
from the outer table, and leaving a wider space filled with healthy
dipIoS.
Again, it is a fact of singular interest, that this thickening, this
hypertrophy of the skull, most commonly, if not always, takes place
especially, and to a greater extent than elsewhere, in the parts of the
bones in and about which ossificatfbn commenced in the fcetal state ; as
if, one might say, some of the potency that of old brought the foetal
membrane of these parts first into the development of bone, were always
afterwards concentrated in them ; or as if a reserve power of growth
had its seat in the same centres where was formerly the originative
power of development. The fact is shown in many of the specimens,
especially in one that is represented in Fig. 4 ; and we may find some
further, though less sure evidence of the peculiar formative energy
of these old centres, in the fact that those diseases of bone which are
accompanied with excessive formation, such as morbid thickenings of
* Medico-ChirurgicBl TraoiaclkiDS, vol. xix, p. 315.
OF BONES. 75
the skull and tnmors are, in a large majority of cases, Beated in or
near the centree of ossification ; jou rarely find them, except at the
articular ends, or
round the middle of ^'e- *■
the shaft. The same
does not hold of ne<
crosis, rickets, ulce-
ration, or other dis-
eases indicative of
depreflsion of the
formative power of
the bone. Bather,
as some specimens
(Nos. 390-1-2) of ricketty disease of the skull and femora show, the
centres of ossification are remarkably exempt from the change of struc-
ture which has extensively affected the later-formed parts.
This peculiarity of the centres of ossification is the more remarkable
when we remember that in many cases, the thickening of the skull
takes place in persons far past the middle period of life ; it may happen
even in very old age, and may give one more evidence of that precision
of assimilation which maintains, throughout life, characteristic distinc-
tions among portions of what we call the same tissue.
Let me, however, remark, that it is not peculiar to old. persons: I
believe that at whatever age, after the complete closure of the cranial
sutures, shrinking of the brain may happen, this hypertrophy of the
skull may be its consequence. One specimen, for instance (No. 3T9),
is part of the skull of a suicide only thirty years old ; another (No.
380), from an idiotic woman, has not the characters of an old skull. I
once examined a remarkable case, showing the same conditions, in a
person less than thirty years old, in whom the thickening of the skull
must have begun in early life. She was a lady of remarkable personal
attractions, hut of slenderly developed intellect, whose head did not,
externally, appear below the average female size. Yet her cranial
cavity was singularly contracted ; the skull had adapted itself to an
imperfectly grown brain, by the hypertrophy of its diploe, which was
nearly half an inch thick at and near the centres of ossification of the
frontal and parietal bones. But this cranial hypertrophy does not
necessarily affect the whole of the bones forming the walls of the brain
cavity. It may be limited in extent, as in those cases in which a par*
tial atrophy of the contents of the cavity occurs, as when one hemi-
sphere only of the cerebrum or cerebellum is diminished in size.*
Such hypertrophy, however, is not always the mode by which the
skull is adapted to the diminished size of the brain. In congenital and
very early atrophy of the brain, the skull is proportionally email, and
* Ad iniemting caie of ibis kind baa been recorded by Prof. 8. Van det Kotk. E^auy
uutbued Id vol. xi,af New Syd. Soc. FuUtcationi, ISSl.
76 HYPERTROPHY
may exactly represent the size and shape of the cerebrum. It does so
in the cases of small-skulled idiots, and in a remarkable skull in the
Museum of St. Bartholomew's Hospital. The man from whom this
skull was taken received a compound fracture of the left frontal bone
when he was only fourteen years old. Portions of bone were removed ;
hernia cerebri ensued, and several pieces of brain were sliced off. But
he recovered, and lived thirty-three years. The left hemisphere of the
cerebrum was altogether small. Where the brain had been sliced off,
its surface had sunk in very deep, and had left a cavity filled with a>
vascular spongy substance containing ill-formed nerve-fibres. You will
observe here, that in the modelling of the skull, the left side has become
in every part less capacious than the right, adapting itself to the di-
minished brain without any hypertrophy of the bones.
The cases are very rare in which hypertrophy of any other bones
than those of the skull occurs in connection with what is recognized as
disease. For, as I have said, the bulk of most of the other bones is
principally determined by the activity of the muscles fixed on them ;
and a morbidly excessive action of muscles, sufficiently continued to
produce hypertrophy of bones, is seldom, if ever, met with.
But there is a condition of bones so similar to hypertrophy in many
respects, and so little different from it in any, that I may well speak of
it here ; yet not without acknowledging that nearly all I know about it
is derived frpm Mr. Stanley.
When any of the long bones of a person who has not yet attained
full stature is the seat of disease attended with unnatural flow of blood
in or near it, it may become longer than the other or more healthy
bone. For example, a lad, suppose, has necrosis of #the femur, it may
be of a small portion of it, and he may recover completely from this
disease ; but for all his life afterwards (as I had constant opportunity
once of observing in a near relative), he may be lame, and the charac-
ter of his lameness will show that the limb which was diseased is now
too long ; so that he is obliged, in walking, to lift the lame leg, almost
like a hemiplegic man, lest his toe should trip upon the ground.
Such cases are not uncommon. I once saw, with Mr. Stanley, a
member of our profession, in whom this elongation of one femur had
taken place to such an extent that he was obliged to wear a very high
shoe on the other ; that is, the healthy limb. And this, which he had
adapted for himself, affords the only remedy for the inequality of limbs.
Nor is the remedy unimportant ; for to say nothing of the unsightly
lameness which it produces, the morbid elongation of the limb is apt to
be soon complicated by one or two serious consequences. Either the
patient in his endeavors to support himself steadily and upright, will
acquire first the habit, and then the malformation of talipes^ of the
healthy limb ; or else, through the habit of always resting on the short,
healthy, and stronger limb, he will have lateral curvature of the spine.
Cases of both these kinds have occurred in Mr. Stanley's practice ;
OF BONES,
77
being brought to him for the remedy, not of the elongated femur, but
of the consequent deformity of the foot or the spine.
A coDsiderable elongation of the lower extremity almost always de-
pends on the femur being thus affected : another, and very characteris-
tic result, ensues from the same kind of hypertrophy when it occurs in
the tibia. The femur can grow longer without materially altering its
shape or direction, but the tibia is tied by ligaments at its two ends to
the fibula ; so that when it lengthens, unless the fibula should lengthen
to the same extent, it, the tibia, must curve ; in no other way except
by the lengthening of the ligaments, which I believe never happens to
any considerable extent, is elongation of the tibia possible.
Tibiie thus curved are far from rare ; specimens are to be found in
nearly every musenm ; yet I know of none in which the pathology of
the disease is clearly shown, except one in the
Museum at St. Bartholomew's (Subser. A, 46),
which is here sketched. Fig. 5. In this, the
fibula, and healthy tibia of the opposite limb,
are preserved with the elongated tibia. The an-
terior wall of this tibia, measuring it over its
curve, is more than two inches longer than that
of the healthy one : the posterior wall is not
quite so long.
In all such specimens you may observe a
characteristic form of the curve, and its distinc-
tion from the curvature of rickets. The dis-
tinction is established by these particulars : the
ricketty tibia is always short ; the other is never
short, and may be longer than is natural : in the
ricketty one the articular ends always enlarge
very suddenly, for the shortening is due to the
imperfect formation of the ends of the shaft ; in
the elongated tibia, there is usually even leas
contrast of size between the shaft and epiphyses
than is natural, because the elongation of the
shaft is commonly attended with some increase
of its circumference: hut, especially, the ricketty
tibia is compressed, usually curved inwards, its
shaft is flattened laterally, and its margins are
narrow and spinous ; while in the elongated tibia,
the curve is usually directed forwards, its mar-
gins are broad and round, its surfaces are convbx, and the compression
or flattening, if thare be any, is from before backwards.
The elongation of the hones in these cases may occur, in difierent
instances, in two ways. In some cases it seems due to that change in
bone which is analogous to chronic inflammation of soft parts, and
which consists in the deposit of the products of inflammation in the in-
78 HYPERTROPHY
terstices of the osseous tissue, their accumulation therein, and the re-
modelling of the bone around them as they accumulate. Such a change
appears to have occurred in the specimen from which the sketch was
taken, and would necessarily give rise, in a growing bone, as it does
in soft parts, to enlargement in every direction, to elongation as well
as increase of circumference.
But in other cases, the elongation is probably due to the more genu-
ine hypertrophy which follows the increased flow of blood. When, for
example, a small portion of bone, as in circumscribed necrosis, is ac-
tively diseased, all the adjacent part is more vascular ; hence may arise
a genuine hypertrophy, such as I have shown in hair under similar
circumstances. Or, when an ulcer of the integuments has long ex-
isted in a young person, the subjacent bone may share in the increased
afflux of blood, and may enlarge and elongate. Even, it appears, when
one bone is diseased, another in the same limb may thus be increased
in length. A remarkable instance of this kind has lately been observed
by Mr. Holden, in a young man, who, in childhood, had necrosis of the
left tibia, one of the consequences of which was defective growth of the
left leg, with shortening to the extent of more than an inch. Yet the
whole limb is not shorter than the other ; for, without any apparent
morbid change of texture, the femur of the same side has grown so as
to compensate for the shortening of the tibia.
An interesting example of similar increased growth of one bone, in
compensation for the weakness of another, is found sometimes in cases
of ill-repaired fractures or diseases of the tibia. The fibula, at the part
corresponding with the weak portion of the tibia, is in such cases
strengthened sufficiently for the support of the limb. So in a specimen
in the Museum of St. Bartholomew's (Ser. 3 ; 86), taken from a dog
ten weeks after a piece of the radius was cut out with its periosteum,
while the gap in the radius is filled with only soft tissue, the exactly
corresponding portion of the ulna is increased by the formation of new
bone beneath its periosteum.
I must not forget to say, that the interest of these cases of inequality
of the limbs, by lengthening of one of the bones, is increased by com-
parison with another class of cases in which a great or greater inequality
of length depends on one limb being anormally short. In these the
short limb has been the seat of atrophy, through paralysis of the mus-
cles dependent on some of the very numerous conditions in which they
may be rendered inactive. The complication of the cases, the talipes,
and the curvatures of the spine, depending, as they do, on the ine-
quality of the length of the limbs, from whatever cause arising, will be
alike in both ; and much care may be needed in diagnosis, to tell which
of the limbs, the long one or the short one, is in error. The best cha-
racters probably are, that when a limb is, through disease or atrophy,
too short, it will be found, in comparison with the other, defective in cir-
cumference as well as in length ; its muscles, partaking of the atrophy,
CAUSED BY PRESSURE. 79
will be weak and flabby, and all its tissues will bear signs of imperfect
nutrition. If none of these characters be found in the short limb, the
long one may be suspected ; and this suspicion will be confirmed, if
there be found in it the signs of increased nutrition, such as enlarge-
ment, growth of hair, and the rest : or if, in the history of the case,
there be evidence of a disease attended with an excess in the supply of
blood.
Continuing to select from the Museum only such examples of hyper-
trophy as may illustrate its general pathology, I pass over many, and
take next, those which display the formation of corns ; a subject which,
while Hunter deemed it worth consideration, we shall not be degraded
by discussing. He made many preparations of corns, to show not only
the thickening of the cuticle, but the formation of the little sac of fluid,
or bursa, between the thickened cuticle and the subjacent articulation.
His design appears to have been mainly, to illustrate the different
results of pressure ; to show how that which is from without produces
thickening ; that from within, thinning and absorption of parts. He
says, having regard to these specimens, '^ The cuticle admits of being
thickened from pressure in all parts of the body ; hence we find that on
the soles of the feet of those who walk much, the cuticle becomes very
thick; also on the hands of laboring men. We find this wherever
there is pressure, as on the elbow, upper part of the little toe, ball of
the great toe, &c. The immediate and first cause of this thickening
would appear to be the stimulus of necessity given to the cutis by this
pressure, the effect of which is an increase of the cuticle to defend the
cutis underneath. Not only the cuticle thickens, but the parts under-
neath ; and a sacculus is often formed at the root of the great toe, be-
tween the cutis and ligaments of the joint, arising from the same cause,
to guard the ligaments below.***
In another place he says, " When from without, pressure rather
stimulates than irritates ; it shall give signs of strength, and produce
an increase of thickening : but, when from within, the same quantity of
pressure will produce waste** [as illustrated in Nos. 120 and 121 in the
Pathological Museum]; " for the first effect of the pressure from with-
out is the disposition to thicken, which is rather an operation of
strength ; but if it exceeds the stimulus of thickening, then the pressure
becomes an irritator, and the power appears to give way to it, and
absorption of the parts pressed takes place; so that Nature very readily
takes on those steps which are to get rid of an extraneous body, but
appears not only not ready to let extraneous bodies enter the body, but
endeavors to exclude them by increasing the thickness of the parts.* *t
It is evident from these passages that Mr. Hunter was aware that
pressure from without might produce atrophy ; though he may appear
* Hunter's Works, vol. i, p. 660. t Ibid. vol. iii, p. 466.
80 HYPBRTROPHY: EFFECTS OF PRESSURE.
to favor the belief, which, I think, is commonly adopted as on his au-
thority, that the direction of the pressure is that which determines its
result. Really, the result seems to depend more on whether the pres-
sure be occasional or constant. Constant extra pressure on a part
always appears to produce atrophy and absorption ; occasional pressure
may, and usually does, produce hypertrophy and thickening. All the
thickenings of the cuticle are the consequences of occasional pressure ;
as the pressure of shoes in occasional walking, of tools occasionally
used with the hand, and the like : for it seems a necessary condition
for hypertrophy, in most parts, that they should enjoy intervals in
which their nutrition may go on actively. But constant pressure,
whether from within or from without, always appears to give rise to
unrepaired absorption : and. most museums contain interesting examples
of its effects.
Some vertebrae in the College Museum (121 A.) illustrate very well
the results of pressure by aneurisms and tumors. So far as themselves
are concerned, the pressure of the aneurism was from without inwards ;
yet they are atrophied*; not ulcerated, but hollowed out, and remodelled
in adaptation to the shape of the aneurismal sac : their cancellous tissue
is not exposed, but, as in the natural state, is <;overed by a complete
thin external layer of compact tissue.
The pressure of a loose mass of bone in the knee-joint (No. 955 in
the same Museum) was from without inwards ; but its result was atro-
phy, as shown in the formation of a deep pit at the lower end of the
femur, in which it lay safely and almost tightly lodged.
Again, the effect of constant pressure is shown in the cases in which
one of the lower incisor teeth of a rodent animal has continued its
growth after the loss of the corresponding upper incisor, and, being no
longer worn down by attrition in growing, attains an unnatural length.
In such a case the extremity of the tooth, turning round so as to form
nearly a complete circle, has come in contact with the side of the lower
jaw, and (like, as they tell, the Fakir's finger-nails growing through
the thickness of his clenched hand) it has perforated the whole thick-
ness of the jaw ; the absorption consequent on its pressure, making way
for its onward course.
A yet stranger example was taken from the body of a woman in the
dissecting-room of St. Bartholomew's Hospital, and the specimen (Ser.
1 ; 232) tells all the history that can, or perhaps need, be given. She
had an aperture in the hard palate, and for remedy of its annoyance
used to wear a bung, or cork, in it. But the constant pressure of so
rough an obturator produced absorption of the edges of the opening,
making it constantly larger, and requiring that the cork should be often
wound round with tape to fit the widening gap. And thus the remedy
went on increasing the disease, till, of all the palatine portions of the
upper maxillary and palate bones, nothing but their margin or outer
shell remains : the rest is all absorbed. The antrum is on each side
ATROPHY: DBQENBRATION. 81
obliterated by the apposition of its walls, its inner wall having probably
been pushed outwards as the plug was enlarged to fit the enlarging
aperture in the palate. Nearly the whole of the vomer also has been
destroyed, and the superior ethmoidal cells are laid open.
Lastly, as an instance in which, in the same part, permanent pressure
produced atrophy and occasional pressure hypertrophy, I may show a
Chinese woman's foot. The bandaging, and constant compression in
early life, produced this diminished growth ; but afterwards, when,
with all the miserable doublings-up and crowding of the toes, the foot
was used in walking, the parts of pressure became the seats of corns.
We may sometimes observe the same contrast after amputations. A
bole may be absorbed in an upper flap where it lies on the end of the
bone, and is subject to the constant pressure of its own weight ; but, in
older stumps, the greater occasional pressure on the artificial limb leads
to thickening and hardening of the parts.
These examples, then, may suffice to show, as I have said, that con-
stant pressure on a part produces absorption ; occasional pressure (espe-
cially if combined with friction) produces thickening or hypertrophy ;
and that these result whatever be the direction of the pressure. And,
yet, let me add that Mr. Hunter was not far wrong, — he never was ;
for nearly all pressures from without are occasional and intermittent,
and nearly all pressures from within, arising, as they do, from the
growth of tumors, the enlargement of abscesses, and the like, are
constant.
LECTURE V.
ATROPHT: DEGENERATION.
I PROPOSE now to consider the subject of Atrophy ; the very con-
trary of the hypertrophy which I endeavored to elucidate in the last
two lectures.
By atrophy is commonly implied, not the cessation or total privation
of the formative process in a part, but its deficiency ; and, as I limited
hypertrophy to the cases in which an increased power is acquired for a
part by the growth, or by the development, of healthy tissue ; so shall
atrophy be here taken to mean only that process by which a part either
simply wastes and is reduced in size, with little or no change of texture,
or else, gradually and regularly degenerates.
By the terms of this limitation it is implied, that, as there are two
modes of hypertrophy, the one with growth, the other with develop-
ment ; so there are two modes of atrophy, the one with simple decrease,
the other with degeneration, of tissue. In both, there is a loss of func-
tional power in the part ; but in one, this loss is due to the deficient
quantity, in the other to the deteriorated quality, of the tissue. But,
82 ATROPHY:
as in hypertrophy the development and the growth of the affected part
usually concur, so, in atrophy, a part which becomes smaller usually
also degenerates, and one which degenerates usually becomes smaller.
Still, one or other of these, either the decrease or the degeneration,
commonly prevails ; and we shall see reasons why the distinction is
very necessary to be made.
Let me first state, and even at some length, what is to be understood
by degeneration, and how its effects may be distinguished from those of
disease.
I implied in a former lecture, that the maintenance of a part in its
nutrition must not be understood as being the maintenance of an un-
changed state : rather, each part may be said to present a series of
minute progressive changes, slowly effected and consistent with that
exercise of its functions which is most appropriate to the successive
periods of its existence.
Now, after a certain length of life, these changes accumulate into a
very noticeable deterioration of all, or nearly all, parts of the body ;
and they suffer a manifest loss of functional power. Thus changed,
we say they are degenerate : these accumulated changes are the signs
of decay, the infirmities of age, the senile atrophy. They are the indi-
cations of defective formative power, and often speak more plainly of
old age than do the years a man may have counted ; they testify that
the power which prevailed over the waste of the body in childhood and
youth, and maintained the balance in vigorous manhood, has now
failed : as the tide, after a flood and a period of rest, turns and ebbs
down.
All the expressions usually employed about these changes imply that
they are not regarded as the results of disease : nor should they oe ;
they are, or may be, completely normal ; and were it not that the forces
which are efficient in degeneration are, probably, very different from
those which actuate the formative processes, we might justly call the de-
generation of advanced age another normal method of nutrition. For,
to degenerate and die is as normal as to be developed and live : the ex-
pansion of growth and the full strength of manhood, are not more
natural than the decay and feebleness of a timely old age ; not more
natural, because not more in accordance with constant laws, as observed
in ordinary conditions. As the development of the whole being, and
of every element of its tissues, is according to certain laws, so is the
whole process regulated by which all that has life will, as of its own
workings, cease to live. The definition of life that Bichat gave is, in
this view, as untrue as it is illogical. Life is so far from being " the
sum of the functions that resist death,'' that it is a constant part of the
history of life that its exercise leads naturally to decay, and through
decay to death.
Of the manner in which this decay or degeneration of organisms en-
sues we know but little. Till within the last few years the subject of
DEGENERATION. 83
degenerations was scarcely pursued : and even of late, the inquiries,
which ought to range over the ^hole field of living nature, have been
almost exclusively limited to the human body.
Yet, it could not be without interest to watch the changes of the
body as life naturally ebbs ; changes, by which all is undone that the
formative force in development achieved ; by which all that was gath-
ered from the inorganic world, impressed with life, and fashioned to or-
ganic form, is restored to the masses of dead matter ; to trace how life
gives back to death the elements on which it had subsisted ; the pro-
gress of that decay through which, as by a common path, the brutes
pass to their annihilation, and man to immortality. Without a know-
ledge of these things our science of life is very partial, very incomplete.
And the study of them would not lack that peculiar interest which ap-
pertains to inquiries into final causes. For all the changes of natural
decay or degeneration in living beings indicate this design ; that, being
gradual approximations to the inorganic state of matter, they lead to
conditions in which the elements of the body, instead of being on a sud-
den and with violence dispersed, may be collected into those lower com-
binations in which they may best rejoin the inorganic world ; they are
such, that each creature may be said to die through that series of
changes which may best fit it, after death, to discharge its share in the
economy of the world, either by supplying nutriment to other organ-
isms, or by taking its right part in the adjustment of the balance held
between the organic and the inorganic masses.
Nor would the student of the design of these degenerations do well to
omit all thought of their adaptation, in our own case, to the highest
purposes of our existence. When, in the progress of the " calm decay'*
of age, the outward senses, and all the faculties to which they minister,
grow dim and faint, it may be on purpose that the Spirit may be in-
vigorate and undisturbed in the contemplation of the brightening
future ; that, with daily renewed strength, it may free itself from the
incumbrance of all sensuous things, or may retain only those fragments
of thought or intellectual knowledge which, though gathered upon
earth, yet bear the marks of truth, and being Truth, may mingle with
the Truth from Heaven, and form part of those things in which Spirits
of infinite purity and knowledge may be exercised.
Moreover (and this is in the closest relation to my present subject),
the changes of natural degeneration in advanced life have a direct im-
portance in all pathology ; because they may guide us to the interpreta-
tion of many similar anomalies which, while they occur in earlier life,
we are apt to call diseases, but which are only premature degenerations,
and are to be considered, therefore, as methods of atrophy ; as defects,
rather than as perversions, of the nutritive process ; or as diseases, only
in consideration of the time of their occurrence.*
♦ One can here haye in view only the cases in which the degeneration affects the whole,
or some oonsiderable part, of an organ ; for it is very probable that some of the degenera-
84 ATROPHY:
The changes that mark the progress of natural decay or degeneration
in old age, and that may, therefore be regarded as the typical instances
of simple defective nutrition, seem to be these : 1. Wasting or wither-
ing; the latter term may imply the usually coincident wasting and
drying which constitute the emaciation of a tissue. 2. Fatty degenera-
tion, including many of what have been called granular degenerations.
8. Earthy degeneration, or calcification. 4. Pigmental degeneration.
5. Thickening of primary membranes.
Of each of these let me cite one or two examples.
Of withering^ or wasting and drying, which is perhaps the commonest
form of atrophy, we have abundant instances in the emaciation of old
age ; in which, while some parts are removed by complete absorption,
others are only decreased in size, and lose the succulency of earlier life.
But this withering atrophy must not be confounded with the mere dry-
ing and collapse of tissues, which ensue in cases in which fluids are dis-
charged in excessive quantity, as in cholera, diabetes, and hemorrhage.
A good illustration of the natural withering of the elementary structures
of a part is afforded in the hardening and drying (cornification) of the
epithelial cells. This is especially exhibited by the tessellated epithe-
lium and cuticle, the cells of which, in their progress from the deeper
to the superficial layers, not only become harder and dryer, previous to
their final separation, but assume a flattened, withered aspect.
The fatty degeneration in senility is best shown, as a general occur-
rence, in the increasing obesity which some present at the onset of old
age, and in the general fact that there is more fatty matter in all the
tissues, and most evidently in the bones, than there is in earlier life ;
while, as local senile fatty degenerations, we find the arcus sentliSj or
fatty degeneration of the cornea, and the accumulating fatty or athero-
matous degenerations of arteries.
The calcareous degeneration is, in old age, displayed in the gradual
increasing proportion of earthy matter in the bones ; in the extension
of ossification to cartilages, which, in all the period of vigor, had re-
tained their embryonic state ; and in the increasing tendency to earthy
deposits in the arteries, and other parts.
It may manifest itself in one or other of two ways, either as a creti-
fication, that is, a mere deposition of lime salts, or as a true ossification,
that is, accompanied by the formation of lacunae and canaliculi, cancel-
lated, and compact tissue, and even, in some cases, periosteum. In
most instances these two forms are so well marked, and the differences
between them, both to the naked eye and the microscope, are so obvious,,
that there can be no difficulty in distinguishing one from the other.
The simple calcareous deposit possesses no definite structure, and is
tions which we see en masse in the organs of the old, or in the seats of premature defect of
nutrition, are the same as occur naturally in the elementary structures or molecules of
organs, when the term of their natural life is ended, previous to their being absorbed aAd
replaced, as it were by one particle at a time, in the regular process of nutrition.
DEGENERATION. 85
generally so fragile as readily to crumble down beneath the fingers,
whilst the true ossific formation presents all the well-known characters
of bone. But it is not unusual to meet with instances of calcareous
degeneration in which it is not so easy to pronounce with certainty if
the formation be true bone or not. In these cases the substance may
be hard and compact, but the existence of a lacunary structure is not
very decided. Small dark-looking spaces, appearing like very imper-
fectly formed lacunae, may occasionally be seen, irregular in size, shape,
and arrangement, and destitute of canaliculi. These remind one some-
what of the imperfect structures met with in the cement and granu-
lar layer of the crusta petrosa of the fang of a tooth. Probably the
best test of the lacunary nature of these irregular spaces would be
the detection in them of nuclei, such as are found in the lacunae of
true bone.
The tendons not unfrequently exhibit true bony growths in their in-
terior, which may either spring from the surface of attachment and
extend for a greater or less distance into their interior, or may exist
as distinct isolated masses in their substance. In the muscles, also,
very extensive bony growths occasionally take place. Mr. Hawkins*
has recorded a very curious case, in which there was a most extensive
formation of bone in the voluntary muscles, and there is in the Museum
of the College a preparation in which nearly all the muscles of the back
have undergone ossification. Whether in cases such as these the bone
is formed in the muscular fibre itself, or originates in the connective
tissue between the fibres, and by its growth produces through pres-
sure atrophy and destruction of the proper muscular substance, has
been made a matter of question, but there are very strong grounds for
believing the latter to be the case ; the formation of bone in connective
tissue being a well-recognized fact in development.
The pigmental degeneration has its best instances in the gradually
accumulating black pigment, spotting and streaking the lungs ; in the
slate or ash color which is commonly seen in the thin mucous mem-
branes of the stomach and intestines of old persons; in pigmental dis-
colorations of the skin, which are manifested in their highest form,
though not necessarily occurring in old persons, in apparent connection
with disease of the supra-renal capsules, as first pointed out by Dr.
Addison ; in the black spotting of the arteries of some animals, in
which pigment seems to hold the place of the fatty degeneration so
usual in our own arteries,t and under some as yet imperfectly under-
stood conditions, in the accumulation of pigment in considerable quan-
* Med. Gaz., vol. xxxiv, 1S44, p. 273.
t In Virchow*8 Archiv., 1859, vol. xvi, p. 564, an abstract is given of an inaugural dis-
sertation by Von Stein, in ^ich it is stated that in sixty-two cases of diseases of the brain
which be examined, pigment was deposited, mostly in the middle and outer coats of the
Teisels, in no less than fiAy-three cases.
86 ATROPHY:
tities, not merely in the walls of the bloodvessels, but even in the tubes
themselves.*
Of the thickening of primary membranes we have indications in the
usual thickening of the tubules of the testes, and, I think, of some
other glands, as their function diminishes in old age ; in the opaque
white thickening of the primary or inner membrane of nearly all blood-
vessels ; and in the thickening of the wall of the cartilage-cells in senile
and some other ossifications. To this, also, we have a strong analogy
in the thickening of the cell-walls of the heart-wood of plants.
These changes, singly or in various combinations, constitute the most
evident degenerations of old age in man. Their combinations give rise
to numerous varieties in their appearance ; such as, e. g.^ the increase
of both fatty and earthy matter in old bones ; the dry, withered, and
darkly-tinged condition of the epidermis ; the coincident fatty and cal-
careous deposits in the arteries ; the thickened walls and fatty contents
of the seminal tubes. But at present, I need not dwell on these, nor
on the conditions which determine the occurrence of one rather than
another mode of degeneration ; for these I cannot tell.
Now if we observe the conditions in which these senile, and there-
fore typical, examples of degeneration are imitated in earlier life, they
are such as indicate that the changes are still to be ascribed to a defect,
not to a perversion, of the conditions of nutrition or of the vital forces.
Thus, these changes are all especially apt to occur in a part of which
the functions are abrogated : a motionless limb wastes or becomes fatty
as surely as an old one does. They are found ensuing when one or
more of the conditions of nutrition are removed, not changed. For
example, a fatty degeneration of part of a heart may ensue when,
through disease of a coronary artery, its supply of blood is diminished.
They often occur in parts that fail to attain the development for which
they seemed to be intended. Thus fatty degeneration usually ensues
in the cells of unfruitful Graafian vesicles, f In short, all their history,
when we can trace it, is that of atrophies.
We may therefore safely hold, that as the changes to which the
several tissues are naturally prone in old age are certainly the results
of defect, not of perversion, of the nutritive process, so are the cor-
responding changes when they happen in earlier life, although, through
their appearing prematurely, they may bear the features of disease.
The distinction between degeneration and disease is essential, though
often it may be obscure. Degeneration, as to its process, is natural,
though it may be premature ; disease is always unnatural : the one has
* A lengthened account of this form of pignnent deposit in the capillaries, especially of
the liver, spleen, brain, and other viscera, has been given by Frerichs in his Clinical -Trea-
tise on Disecises of the Liver. In the Medico>Cbirurgical Review, 1861 (vol. xxvii), Dr.
Laycock has published an article on morbid, cutaneous, pigmentary changes, in which the
question of pigment deposits is discussed very fully.
f Reinhardt, in Traube's Beitr'dge, B. i, p. 145.
DBOBNBRATION. 87
its origin within, the other without the body : the one is constant, the
other as various as the external conditions in which it may arise : to
the one we are prone, to the other only liable.
The general diagnostic characters of degenerations are chiefly these:
1. They are such changes as may be observed naturally occurring,
in one or more parts of the body, at the approach of the natural
termination of life, or if not then beginning, yet then regularly in-
creasing.
2. They are changes in which the new material is of lower chemical
composition, t. e., is less remote from inorganic matter, than that of
which it takes the place. Thus fat is lower than any nitrogenous organic
compound, and gelatine lower than albumen, and earthy matter lower
than all these.
3. In structure, the degenerate part is less developed than that of
which it takes the place : it is either more like inorganic matter, or less
advanced beyond the form of the mere granule or the simplest cell.
Thus, the approach to crystalline form in the earthy matter of bones,
and the crystals in certain old vegetable cells, are characteristic of
degeneration ; and so are the granules of pigment and of many granular
degenerations, and the globules of oil that may replace muscular fibres
or the contents of gland-cells, and the crystals of cholesterine that are
often mingled with the fatty and earthy deposits.
4. In function, the part has less power in its degenerate than in its
natural state.
5. In its nutrition, it is the seat of less frequent aild less active
change, and without capacity of growth, or of development.
Such are the characters by which in general we might separate the
processes and results of degeneration from those of disease, and of
natural nutrition. But we must remember always that the process of
degeneration may concur with either of those from which, in its typical
examples, it may be so clearly separated. It may mingle with develop-
ment ; or, at least, by a process of degeneration, a part may become
adapted to a more developed condition of the system to which it belongs.
So it is in the process of ossification. It is usual to speak of cartilage
as being developed into bone, and to regard bone as the more developed
and more highly organized of the two tissues. But I think it is only in
a very limited sense that this mode of expression is just. Professor
Owen, in some admirable remarks* on the cartilaginous state of the
endo-skeleton of Chondropterygian fishes, has said: ^' I know not why
a flexible vascular animal substance should be supposed to be raised in
the histological scale because it has become impregnated, and, as it
were, petrified by the abundant intussusception of earthy salts in its
areolar tissue. It is perfectly intelligible that this accelerated progress
to the inorganic state may be requisite for some special office of such
* Lectures on Comparative Anatomy, vol. ii, p. 146.
88 ATROPHY:
calcified parts in the individual economy ; but not, therefore, that it is
an absolute elevation of such parts in the series of animal tissues." Let
me add, that all that one sees of the life of cartilage, in the narrower
survey of the higher mammalia, is conformable with this view, and
would lead us to speak of its change into bone as a degeneration, rather
than a development. The change is effected not only in the vigor of
life, but as constantly, in certain parts, in its decay ; and, whenever it
is effected, the part that has become bone almost ceases to grow, except
by superaddition : the interstitial changes of normal nutrition are
reduced to their lowest stage. Cartilage, too, is less frequently and
less perfectly repaired after injury than bone is ; and its repair is com-
monly effected by the production of bone ; yet it is contrary to all
analogy for a lower tissue to be repaired by the formation of a higher
one. It may be added that the granular, and in some instances even
crystalline, form, in which the earthy matter of bone is deposited, is
inconsistent with the supposition that its animal matter has acquired a
higher development than it had before in the state of cartilage. So far,
therefore, as its position in the series of animal tissues is concerned,
bone should be placed below cartilage ; as a tissue which has degene-
rated into a state of less active life, and has acquired characters that
approximate it to the more lowly organized and to the inorganic sub-
stances. An osseous skeleton is, indeed, proper to the most highly
developed state of the individual, and in this relative view bone appears
superior to cartilage ; but, with as much right, in the same view, the
atrophied thymus gl&nd, and the renal capsules almost arrested in their
growth, might claim to be regarded as developments from their foetal
state ; for these, also, are normal parts of the more perfect organism ;
they are like the degenerate members of an ennobled society, except in
that, in their humiliation, they augment the common weal.
The points of contact, and even of complete fusion, are yet more
numerous between degeneration and disease. In many diseases, proba-
bly even in the whole class of inflammations, a degeneration of the
affected tissue is a constituent part of the morbid process ; and in many
cases we must still doubt whether the changes of texture that we ob-
serve are the results of degeneration or of disease. Among these are
the instances of the simple softening of certain organs, such as the
brain and spinal cord, and the liquefactions of inflammatory exudations
in the suppurative process. If we limit the term degeneration to the
changes that imitate the typical examples of old age, these changes
cannot be included under it ; but they may be if we consider the con-
ditions in which they occur, and the mere decrease of power which some
of them manifest. The softening of the brain and spinal cord, for
example, occurs in some cases through mere defect of blood ; in some
through mere abrogation of function ; it is often concurrent with 8is-
tinct signs of atrophy ; and, as I shall describe in the next lecture, it
is attended with changes that closely imitate those of fatty degenera-
DEGENERATION. 89
tion. On the whole, therefore, while admitting the difficulty that must
often occur in endeavoring to separate such changes as these from the
effects of disease, or of local death, yet I think we should do well to
classify them under such a title as that of ^Miquefactive degenera-
tion."*
* This is perhaps the best place to advert to a peculiar pathological condition, to which
much attention has been of late years directed, under the name of Amyloi'l degeneration.
It must be confessed, however, that its pathological history is, at present, very defective, so
that we are but imperfectly acquainted, not only with the exact nature *of the substance
found in this so^alled degeneration, but even with the conditions under which its formation
takes place. Neither can we say with any certainty, that it, like the degenerations already
enumerated (p. 84), marks the progress of natural decay, or degeneration in old age.
Although the name "amyloid" has been but recently given by Virchow to the substance
which produces the peculiar waxy, or sago-like appearance, so characteristic of the presence
of amyloid, in the organs or textures, yet in its best marked forms, at least, the occasional
existence of an abnormal material in them had been already recognized, and described as
the lardaceous, or waxy degeneration. Virchow had in the first instance observed (Ar-
chiv, vol. vi, p. 135), that when iodine was added to the round concentric bodies found in
the ependyma of the ventricles of the brain, a blue color was produced, which was changed
to a beautiful violet on the addition of sulphuric acid. From these reactions he supposed
that these structures were of the nature of cellulose, and he named them corpora amylacea.
He subsequently extended his researches to morbid textures (Archiv, vol. vi, et seq.), and
found that when a solution of iodine was brushed over the surface of parts presenting the
wax-like change, that a dark yellowish-red color was produced, which, on the careful addi-
tk>n of sulphuric acid, was converted to a blue or violet. Certain resemblances in color,
under the use of the same reagents, were thus shown to exist between the corpora amyla-
cea of the brain and the peculiar material present in the waxy degeneration, from which it
was supposed that an identity, or close resemblance in chemical composition, existed be-
tween them. These conclusions of Virchow respecting the chemical nature of this material
are far from being generally accepted by pathologists, amongst whom there is much
difference of opinion as to its composition. And, indeed, it is not difficult to see why such
diversities of opinion should exist, when we consider how it is incorporated with the sub-
stance of the normal textures; how hard it must therefore be to free it from them and from
bkx)d, so as to isolate it in sufficient quantities for analysis. Thus we find that H. v.
Meckel (Annal. des Charite Krank. Jahrgang, iv) argues in favor of its being cholesterine.
C. Schmidt, again (Annalen der Chemie, 6. ex, p. 250), concludes from his analyses that it
is not an oxy-bydrocarbon analogous to the non nitrogenous cellulose, but a nitrogen-contain-
ing compound. He was unable to convert it into sugar. Messrs. Bristowe and Ord (Trans.
Path. Soc. Lond., voL x) are inclined to regard it as allied rather to fibrine than to amyla-
ceous matters. Dr. Harris (On the Nature of the Substance found in the Amyloid Degene-
ration, 1860) considers that its reactions indicate its analogy, not its perfect identity, with
the substances of the amylaceous group. Whilst Billroth (Beitr&ge zur Path. Histologic)
thinks that it is proved that amyloid is neither pure cholesterine, nor pure starch or
cellulose, but a body of complex composition, the exact nature of which has yet to be
discovered.
But, whatever be its chemical composition, there can be no doubt that a substance,
presenting the reactions with iodine and sulphuric acid already described, is under some
pathological conditions most extensively distributed in the organs and textures of the body.
It has been especially demonstrated in the liver, spleen, kidneys, lymphatic glands, intestinal
canal, and even in cartilage. It occurs as an amorphous, homogeneous material, infiltrated
into the very substance of the texture, and primarily affects the small arteries, in the fibro-
cellsof the middle coat of which it is apparently first deposited. The arterial walls in this
manner gradually become thiekened, and the calibre of the vessel diminished so that the
part assumes an ansemic appearance. From the bloodvessels it may extend to the proper
7
\
90 FATTY DEGENERATION.
The sum of this discussion respecting degenerations is as follows :
We observe certain changes naturally ensuing in the tissues during
advanced age, and we ascribe these to defect, not to disorder, of the
formative process : we notice the same or similar changes in earlier life,
and we refer them to a similar defect, and class them as methods of
atrophy ; we seem justified in thus regarding them, by the general fact
that they often have the same origin, and are concurrent, with the
atrophy which is attended with merely defective quantity of tissue ; and
lastly, we regard certain changes of texture, such as some forms of
softening of organs, as degenerations or atrophies, because, though they
are not natural in old age, they occur in nearly the same conditions,
and manifest some of the same characters, as the atrophies which
imitate those of senility.
Among the degenerations that I have enumerated, that which may
best be used for general illustration of the whole process, is the fatty.
This deserves a full description, first, because of its own great impor-
tance in pathology, for there is scarcely a natural structure or a pro-
duct of disease in which it may not occur; and secondly, for its
illustration of the general doctrine of defective nutrition, and for
guidance in the study of the degenerations that are at present less
understood. For we may be nearly sure, that general truths, deduced
from examples of fatty degeneration, will hold equally of the other
forms, and especially of the calcareous and pigmental ; between which
and the fatty degenerations there are so many obvious features of close
resemblance, that I shall content myself, having enumerated them, with
tissues of the organs, and exist in the secreting cells of a gland so as to commiinicate the
peculiar, dull, semitransparent, wax-like appearance to the texture.
But although sufficient evidence has not yet been adduced to justify one in concluding
that the amorphous material infiltrated into the substance of parts in the amyloid degenera-
tion is cellulose or starch, yet there appear to be strong grounds for supposing that starch,
in its granular or corpuscular form, may exist ih the normal textures. The corpuscula
amylacea, already referred to as occurring in the brain, are regarded by several trustworthy
observers as true starch-corpuscles. Mr. Busk (Quart. Jal. Mic. Science, Jan., 1854) was
the first who distinctly affirmed, from their structural, physical, and chemical properties,
this correspondence; and Virchow himself, who at one time regarded them as cellulose,
now looks upon them as exhibiting a complete analogy to vegetable starch. (CeUular
Pathologie, Lect xiii.) In the prostate gland, also, peculiar laminated concretions have long
been known, which give to iodine the blue reaction of starch, and which, as Paulizky has
recently shown (Virchow's Archiv, vol. xvi, p. 147, 1859). can, by means of saliva, be con-
verted into sugar. Dr. Carter (Edin. Med. Jal., August, 1865, and March, 1858) not only
pronounces the corpora amylacea to be starch, but contends, and adduces many observations
in support^ of his statement, that starch granules are extensively distributed in the tissues
and organs of the body, and that they are physiological products of the animal organism.
Dr. Carter has also observed their presence in certain pathological new formations, and Dr.
Beale has found numerous bodies exactly resembling starch granules in a cancerous liver.
(Gulstonian Lectures, p. 01.) Mr. Lockhart Clarke has also noticed a considerable deposi-
tion of the corpora amylacea around the central canal in i case of disease of the spinal
cord. (Beale's Archives, October, 1801.)
FATTY DEGENERATION. 91
merely referring to the examples of them that will be described in future
lectures.*
The anatomical characters of many examples of fatty degeneration
will be described in the next and in subsequent lectures. Their princi-
pal general feature is, that in the place of the proper substance of an
elemental structure, e. g.y in the place of the contents or the nucleus of
a cell, or in the very substance of a simple membrane, a blastema, or a
fibre, minute particles or granules are seen, which are recognized as
consisting of oily or fatty matter, by their peculiar refraction of light,
their solubility in ether, their aptness to coalesce into larger oil-drops,
and, when they are very abundant, by the greasiness of the whole
tissue, its burning with a bright flame, and its yielding to analysis an
unusual quantity of fatty matter. In examining organs in the state of
fatty degeneration, we may commonly see the progress of the change
in the gradual increase of the fatty particles. Some cells, for example,
may appear quite healthy ; some may deviate from health only in con-
taining two or three shining, black- bordered, oil-particles ; in others,
these are increased, and a large part of the cell-cavity is filled with
minute oil-particles, or with one or more larger oil-drops ; and in others,
the contents of the cell have given place to a single cluster of oil-drops.
In this last case, the degeneration is nearly complete : the transformed
cell is called a "granule-cell," or, when, as it often happens, the cell-
wall has wasted and disappeared, it is a "granule-mass ;'' and the last
stage of degeneration is that such masses may break up, their con-
stituent molecules may dispart, and the tissue which was an aggregate
of nucleated cells may become little more than a mass of molecules or
drops of oily matter.
It is probably due in part to such disintegration of degenerate cells,
that, in most organs thus degenerate, abundant fatty matter is found
free, that is, lying in drops not enclosed, among the proper constituents
of the tissue. But this free fat is also derived, in part, from the
degeneration of intercellular substance, which is usually concurrent
with that ensuing in the cells ; and in some cases (as Virchow has
observed in the liver) it so follows the arrangement of minute blood-
vessels that it may be considered as the residue of a direct deposit from
them.
In most instances the fatty degeneration afiects, first and chiefly, as
I have described it, the contents of cells or tubules, or the proper sub-
stance of membrane or other tissue. And when it thus happens, the
nuclei almost always waste, and either shrivel or disappear after
gradually fading in their outlines. This may be commonly seen in the
fatty degeneration of the renal and hepatic cells, and of the muscular
fibres ; and it is a fact of some significance, when we remember the
constancy and abundance 0/ nuclei in actively growing parts. But, in
* The index will afford at once a sufficient guide to these examples.
92 FATTY DEGENERATION.
certain cases, as in fatty degeneration of cartilages, the change appears
to begin in the nuclei, which are gradually transformed into granule
masses, while the cell-wall may remain unchanged, or may become
thickly walled or laminated, or may coalesce with the surrounding
tissue.
Such a transformation of a nucleus, while it retains its place and
general form, might at once suggest that the fatty matter which collects
in these degenerations is not introduced from without into the cells or
other elements of the tissues ; that it is not placed in them, as it may
be in the parts around them, as a morbid deposit, but rather is one of
the products and residues of some chemical transformation which they
undergo when the proper nutritive changes are suspended. We might
derive the same suggestion from the similarly degenerate muscular
fibres ; in which we may often find the fat particles arranged in the
same manner as the proper constituents of the fibrils, and looking as if
there were a gradual transformation of the " sarcous elements** into the
little oily particles, which, by clustering, and then by fusion, at length
compose the larger oil-drops.
We gain other and better evidence of the fatty matter being derived
from chemical changes in the tissue that is degenerate, from many other
sources. Such changes are exemplified in the production of fatty mat-
ters during the spontaneous decompositions of nitrogenous substances.
Many instances* of this are known, but none are so appropriate as the
formation of adipocere in muscular tissue. Here, as Dr. Quain dis-
covered, the places of the muscular fibres, bloodvessels, and nerves, are
occupied by fatty matter, which could not have existed in them during
life, which is far too abundant to have been derived from changes in
the fatty matter that they naturally contain, and which, in confused
crystals, retains their natural shape, size, and arrangement. And
Dr. Quain has completed the evidence of the chemical nature of these
degenerative changes, by an artificial imitation of them. He has shown
that the textures of hearts (and the same is true of other parts), when
placed in very dilute nitric acid, or in diluted spirit, pass into a condi-
tion exactly resembling that of the fatty degeneration which I have
been describing.f No fact could be more apposite to prove that this
form of degeneration is an atrophy ; for we may be very sure that when
imitable chemistry prevails in a part, the forces of life, even in those of
morbid life, are defective or suspended in it.
The whole history of fatty degenerations concurs to prove that they
* Many are collected by Virchow, in his Arcliiv, B. i, p. 167; and others by Dr. Quain,
Med. Chir. Trans, vol. xxxiii, p. 140, et seq. The facts concerning the formation of sugar
from nitrogenous compounds in the liver are of the same kind.
■f Dr. Quain has candidly referred to many previous observe! s by whom similar changes
were recognized ; but the honor of the full proof, and of the right use of it, belongs to him-
self alone. Respecting the method of the chemical transformations by which the change is
accomplished, the best essay is, I think, that of Virchow (Archiv, B. i, p. 152).
FATTY DBGENERATION. 93
are the result of defect, not of disease, of the nutritive process; and
that they may be therefore classed with the atrophy which we recognize
in merely diminished quantity of formation. Let me point out the
chief features of this history : for even some repetition of the earlier
part of the lecture will be justified by the utility of assigning their
right place in pathology to changes of which (as is the case with all
these degenerations) we are every year gathering new and very impor-
tant illustrations. ,
I have said that the types or standards of degenerations are the
changes naturally ensuing in old age. Now, accumulations of fat,
which in many parts, assume the forms of the fatty degeneration of
tissues, are striking characteristics of old age, and especially of the
commencement of senile infirmities. The results of senile atrophy are
not, indeed, the same in all persons : rather, you find among old people,
and you might almost thus arrange them into two classes, the lean and
the fat ; and these, as you may see them in any asylum for the aged,
impersonate the two kinds of atrophy I have spoken of, as the withering
and the fatty degenerations.
Some people, as they grow old, seem only to wither and dry up ;
sharp-featured, shrivelled, spinous old folk, yet withal wiry and tough,
clinging to life, and letting death have them, as it were, by small in-
stalments slowly paid. Such are the ^^ lean and slippered pantaloons ;"
and their "shrunk shanks'' declare the pervading atrophy.
Others, women more often than men, as old and as ill-nourished as
these, yet make a far different appearance. With these the first sign
of old age is that they grow fat ; and this abides with them till, it may
be, in a last illness sharper than old age, they are robbed even of their
fat. These, too, when old age sets in, become pursy, short-winded,
pot-bellied, pale and flabby ; their skin hangs, not in wrinkles, but in
rolls; and their voice, instead of rising "towards childish treble,"
becomes gruff and husky.*
These classes of old people, I repeat, may represent the two chief
forms of atrophy ; of that with decrease, and that with fatty or other
degeneration of tissues. In those of the first class you find all the
tissues healthy, hardly altered from the time of vigor. I examined the
muscles of such a one; a woman, seventy-six years old, very lean,
emaciated, and shrivelled. The fibres were rather soft, yet nearly as
ruddy and as strongly marked as those of a vigorous man ; her skin,
too, was tough and dry ; her bones, slender indeed, yet hard and clean ;
her defect was a simple defect of quantity, and of moisture.
♦ Mr. Barlow, in some admirably written ** General Observations on Fatty Degeneration'*
{Medical Times and Gazette, Mny 15, 1802), bas pointed out that the climacteric disease,
described by Sir H. Halford, and the " Decline of the Vital Powers in Old Age," described
by Dr. Marshall Hall, are probably, in great measure, dependent on such fatty degeneration
as these persona extremely exemplify.
94 FATTY DEGENERATION.
But in those that grow fat as they grow old, you find, in all the
tissues alike, hulk with imperfect texture ; there is fat laid between,
and even within, the muscular fibres ; fat about and in the fibres of the
heart, in the kidneys, and all the vessels ; their bones are so greasy
that no art can clean them : and they are apt to die through fatty
degeneration of some important part, such as the heart, the minute
cerebral bloodvessels, or tl^e emphysematous lungs. The defect of all
these tissues is the defect of quality.
Now, I do not pretend to account for this great difference in the
concomitants of the other infirmities of old age in different people.
The explanation probably lies far among the mysteries of the chemical
physiology of nutrition, of the formation of fat, and of respiratory ex-
cretion ; and we may hope to find it when we know why, out of the
same diet, and under all the same external conditions, one class of men,
even in health and vigor, store up abundant fat, and another class
excrete the elements of fat. In relation, however, to the present sub-
ject, the main point is, that the similarity of the conditions in which
they occur implies similarity in the essential nature of the two changes,
and that the defective quantity and the defective quality of the tissues
are both atrophies.
The same conclusion may be drawn from the frequent coincidence of
the two methods of degeneration in the same part. In thedimbs, the
most common form of atrophy from disease is manifested in diminution
of size, together with increase in the fatty matter combined with the
muscles and bones. Such is the condition usually displayed by the
bones and muscles of paralyzed limbs ; in the majority of atrophied
stumps after amputation ; and in many other similar cases.
In like manner, the fatty degeneration of a part is commonly seen as
the consequence of the very causes which, in other instances, give rise
to simple wasting or emaciation of the same part. Thus, when the
function of a part is abrogated, from whatever cause, the part may in
one person shrink, in another degenerate into fat. The emaciation of
a paralyzed limb is a familiar object : but in some cases the muscles of
paralyzed limbs are hardly reduced in size, but are all transformed into
fat. In the College Museum there is a pancreas, with a cancerous
tumor pressing on its duct, and all behind the part obliterated is
degenerated into fat ; and in the Museum of St. Bartholomew's there is
also a pancreas, the duct of which was obliterated ; but in this, the part
behind the obstruction is simply shrivelled, dry, hard, and scarcely
lobulated. So, too, among the bones atrophied in different bed-ridden
persons, some are exceedingly light, small, and dry : others are not
small, but very greasy, full of fatty matter. Either of these results
also, or the two mingled in various proportions, may result from de-
fective supply of blood ; as in the cases of atrophy of parts of bones
after fractures, as described by Mr. Curling, to which I shall have
again to refer. So that from these, and from many other cases here-
FATTY DEGENERATION. 95
after to be mentioned, we may say generally, that nearly all the
ordinary causes of atrophy may produce, in any part, in one case re-
duction of size, in another fatty degeneration, in another a concurrence
of the two.
Much yet remains to be said of this important change : but it will be
more appropriate to the next and other lectures, in which I shall
describe the fatty degenerations of several parts, and of the products
of inflammation and other diseases, as well as that remarkable form of
the degeneration which ensues, with the rapidity of an acute disease,
in the proper textures of some inflamed parts. It seems only necessary,
in conclusion, to state that there appears no necessary, or even frequent,
connection between the fatty degeneralion of any organ in particular,
and that general tendency to the formation of fat which constitutes
obesity. No doubt, a person, especially an elderly one, who has a
natural tendency, even when in health, to become corpulent, will,
ecEteris paribuSj be more likely to have fatty degeneration, than to have
a wasting atrophy, in any organ which may fall into the conditions in
which these changes originate. And, as a general rule, spirit-drinking,
and the excessive use of hydro-carbonaceous articles of food, while
favoring a general formation of fat, are apt to give rise to special fatty
degeneration in the liver, or some other organ. Yet, on the other
hand, one commonly finds the proper elements of the tissues — the
heart, the liver, and the rest — quite healthy in men who are very cor-
pulent. The muscular fibres of the heart, or of the voluntary muscles,
may be imbedded in adipose tissue, and yet may be themselves free
from the least degeneration. So, also, the hepatic cells may be nearly
free from fat within, though there be much oil around them. Fat
accumulated in tissue round the elements of a part is a very different,
probably an essentially different, thing from fat within them ; the one
is compatible with perfect strength, the other is always a sign of loss
of power. In the muscles of some fish, such as the eel, it is hard to
get a clear sight of the fibres, the oily matter around them is so abun-
dant : but the fibres are peculiarly strong, and, in their own texture,
make a striking contrast with the fibres of a degenerate muscle, in
which the fat is, in great part, within.
The same essential distinction between general and local fat-forma-
tion, though they may often coincide, is shown in the fact that the local
formation very often happens in those whose general condition is that
of emaciation, as in the phthisical and chlorotic.
On the whole, therefore, we must conclude that something much
more than a general tendency to form fat, or a general excess of fat
in the blood, is necessary to produce a local fatty degeneration. The
general conditions are favorable, but not essential, to this form of
atrophy.
96 ATROPHY.
LECTURE VL
ATROPHY.
The last lecture was chiefly occupied with a general account of
those changes of texture which are to be regarded as atrophies ; and
now, having pointed out what affections may be classed under this
term, the whole subject may be more largely illustrated by particular
examples.
First, as to the conditions in which atrophy, whether with decrease
or with degeneration, may ensue. Many of them may be most easily
explained as the very contraries of the conditions in which hypertrophy
originates. Thus, as we have seen that when a part is, within certain
limits, over-exercised, it is over-nourished ; so, if a part be used less
than is proper, it suffers atrophy. For instance, in the Museum of
St. Bartholomew's (Ser. 12 ; 57) is the heart of a man, fifty years old,
who died with cancer of the stomach in extreme emaciation. It is
extremely small, and weighed only five ounces four drachms; whereas,
according to the estimates of Dr. Clendinning, in a healthy man of the
same age the heart weighs upwards of nine ounces. But, small as it is,
this heart was adapted to the work it had to do ; and in this adaptation
we have the purpose of its atrophy. For, because of his cancer, the
man had less blood, and needed less force of the heart to propel it : so
that, in direct opposition to what I described as the course of events in
hypertrophy, here, as the quantity of blood diminished, and the waste
of the heart by exercise in propelling it diminished, so the repair of the
waste diminished somewhat more than the waste itself did : and the
heart, though less wasted, became smaller, till it was only large enough
for the propulsion of the scanty supply of blood.
The same may be said of a heart of which there is a drawing in the
same Museum. It was taken from a woman twenty-two years old, who
died with diabetes. It weighed only five ounces ; yet, doubtless, it was
enough for her impoverished supply of blood.
It would be superfluous to describe many instances of atrophy
through defective exercise, or abrogated function of parts. The wasted
and degenerate limbs of the bed-ridden, the shrunken brains of the
aged and the imbecile, the withered ovaries and uteri of many barren
women, are good examples of defective nutrition adapted to defective
exercise of function : and so ar-e the atrophied distal parts of nerves
whose trunks have been divided, and the atrophied columns of the
spinal cord that correspond with inactive portions of the brain. The
rapid degeneration and removal of the tissue of the uterus after par-
turition, and the rapid disappearances of temporary organs of various
kinds, are as striking examples of atrophy following the abrogation or
completion of oflice. To some of these examples I shall again refer.
ATROPHY. 97
It is in similar contrast with the history of increased growths, that,
as an excess of the constituents of which a tissue may form itself pro-
duces hypertrophy of that tissue, so may defect of those constituents
produce atrophy. Thus, the quantity of adipose tissue diminishes even
below what is natural to the several parts, as often as the fat-making
constituents are deficient in the food, and therefore in the blood. So,
the formation of bones is defective during deficiency of the supply of
bone-earths ; the mammary glands waste when the materials for the
formation of milk are imperfectly supplied ; and the whole body wastes
in general defect or poverty of blood.
. Again, as I showed instances in which the increased flow of healthy
blood through a part produced hypertrophy, so are there more numer-
ous examples of merely defective nutrition in consequence of a dimin-
ished supply of blood. Some of the most striking of these were first
described by Mr. Curling,* in cases of fractured femora and other
bones, showing atrophy of that portion which, by the fracture, was cut
off from the supply of blood through the great nutritive or medullary
artery. The consequence of the withdrawal of so much of the blood
from the upper or lower fragment, according to the position of the frac-
ture, is not death ; for the anastomosis between the vessels of the wall
and those of the medullary tissue of the bone is enough to support life,
though not enough to support vigorous nutrition ; but the frequent con-
sequence of the fracture is an atrophy of the part thus deprived of a
portion of its ready supply of blood.
Similar instances are seen in the decrease or degeneration of portions
of hearts when single branches of a coronary artery are obstructed ;t in
the wasting of a portion of kidney when a branch of a renal artery is
closed ;X and in local softening of the brain, with obliteration of single
cerebral arteries.§
In all these instances we see that conditions contrary to those giving
rise to hypertrophy produce atrophy. But there are many other con-
ditions from which atrophy in a part may ensue : defects in quantity,
or in the constitution of the blood ; defective or disturbed nervous influ-
ence, as through excessive mental exertion ; the disturbances of disease
or injury, as in inflammation, specific morbid infiltrations, &c. In
short, whatever interferes with or interrupts any of those conditions
which I enumerated as essential to healthy nutrition, may give rise to
atrophy, either general or local. The clinical history of the fatty de-
generation of the heart, so largely illustrated by Dr. Ormerod|| and
Dr. Quain,^ may best prove how multiform are the events from which
the atrophy of a single organ may arise.
* Medico-Cbirorg. Trans, vol. zx.
t Quain, Medico-Chir. Trans, xxxiii, p. 148 ; Virchow, Archiv, iv, p. 387.
X Simon, Lectures on Pathology, p. 94. § Kirkes, Med. Chir. Trans, vol. xxxv.
I Medical Gazette, 1849. IT Medico-Chirurgical Trans, vol. xxxiii, 1850.
98 ATROPHY OF
But besides all the instances in which atrophy of a part may arise as
a secondary process, there are others in which we are so unable to trace
its precedents, that we are tempted to speak of it as primary, or spon-
taneous, in the same sense as we might so call the natural wasting of
the Wolffian bodies, the thymus, and other temporary organs. It is as
if an atrophy of old age, instead of affecting all parts simultaneously,
took place prematurely in one.
Whatever the true explanation may be, most of the parts of the body
appear to be subject to this seemingly spontaneous atrophy ; and it
generally manifests itself in some form of degeneration. Its most fre-
quent seats are the heart and arteries, the bones, muscles,'*' liver, and
kidneys ; but it occurs also in the pancreas and the salivary glands,
in the testicle, and even in the blood. It is yet more frequent in mor-
bid products, as in the exudations of inflammation, and tumors of every
kind.
The contrast between hypertrophy and atrophy is, thus, nearly as
great in the number, as in the kind, of the conditions in which they may
severally arise. And, once more, we niay contrast them in regard to
the mode in which the vessels and nerves adapt themselves. As a part
becomes atrophied, its bloodvessels and its nerves are consequently and
proportionally changed. In atrophy of the eye, the optic nerve and
artery diminish ; and, in a case of fatty degeneration of the adductor
muscles of the thigh, in consequence of disease of the hip-joint, I found
corresponding atrophy of their nerves. The atrophy of the nerves
* The publication by Dr. Meryon, a few years ago (Trans. Med. Chir. Soc. vol. 35) of a
remarkable series of cases in which fatty degeneration of the voluntary muscles appeared
to arise as a primary, or spontaneous affection, has prominently directed the attention of pa-
thologists in this country to the subject. It has also been carefully investigated on the Con-
tinent by Cruveilhier, Duchenne, Aran, Oppenheimer, Wachsmuth, and others. The best
historical and analytical account of the disease which has yet appeared is by Dr. Roberts,
in his " Essay on Wasting Palsy," 1858. He argues for the spontaneous origin of the de-
generation. But there are not wanting pathologists who look for the cause of this muscular
atrophy, not in the muscles themselves, but in the centres from which the nerves that sup-
ply them spring. A case has just been published by Dr. RadclifTe and Mr. Lockhart Clarke
(Med. Chir. Rev. July, 1862), which confirms, at least in this particular instance, this view
of the cause of the lesion. The patient, a male ret. forty, was greatly emaciated. The
relics of his muscles were tense and rigid, and altogether disobedient to the will. The cord,
on being examined microscopically by Mr. Clarke, exhibited a remarkable change in the
nerve-cells, which were reduced in number, altered in shape, and singularly atrophied.
Tlie columns of the cord were also atrophied or degenerated. In another case, recorded
by Dr. W. T. Gairdner in Beale's Archives, October, 1861, in which the cord was examined
by Mr. Clarke, atrophy of the muscles of the upper limbs was accompanied by lesion of the
cervical part of the cord; and in a third case, by Dr. Gull (Guy's Hospital Reports, vol. viii,
p. 244, 1862), in which there was progressive atrophy of the muscles of the hands, the
post mortem examination revealed a considerable dilatation of the ventricle of the cervical
part of the cord, and atrophy of the gray matter.
More extended observations on these cases of wasting palsy may perhaps teach us that
in looking for the causes of muscular atrophy we may have to distinguish two distinct sets
of cases, one In which degeneration of the muscles arises as a primary affection, the other
in which it results from a lesion of the nervous centres from which the nerves that supply
the muscles arise.
VOLUNTARY MUSCLES. 99
must have -been, in this case, secondary: the course of events being,
inaction of the muscles in consequence of the disease of the joint ; then,
atrophy of them in consequence of their inaction ; and, finally, atrophy
of the nerves following that of the muscles.
From these general considerations I proceed to speak particularly of
Atrophy, as it manifests itself in some of the principal organs and tis-
sues of the body ; — and first of the Atrophy of Muscles.
The affection has been well studied in all the three forms of muscu-
lar tissue ; namely, in the voluntary muscles, in the heart, and in the
organic or smooth-fibred muscles ; and I will describe it in each of these
m order.
The voluntary muscles exhibit, in different conditions, both the chief
forms of atrophy ; that, namely, with decrease or wasting, and that
with fatty degeneration.
In a wasted muscle, such as one sees, for example, in the limbs of
those who are only emaciated, the fibres may appear almost perfectly
healthy : they are rather paler, indeed, and softer, and more disposed
to be tortuous, than in the natural state ; for muscles are commonly
withered when they are thus reduced in size ; yet their transverse striae,
and all their other characteristic features, are well marked.
In the state of fatty degeneration, the whole of a voluntary muscle
may appear pale, bleached, or of some yellowish or tawny hue, soft and
easily torn. But a more frequent appearance is that in which fasciculi
in the healthy state, and others in various degrees of degeneration, lie
in parallel bands, and give the whole muscle a streaky appearance, with
various hues, intermediate between the ruddiness of healthy flesh, and
the dull, pale, tawny-yellow, or yellowish-white, of the complete de-
generation. In such a case (and this may appear remarkable) healthy
primitive fibres may lie among those that are degenerated. Of the lat-
ter, some, in place of the transverse stri», present dark very minute
dots arranged in transverse lines ; in others, the whole fibre has a dim,
pale, granular aspect, with no definite arrangement of the granules ; in
others, little oil-globules adhere to the interior of the sarcolemma ; and
in others, such globules are collected more abundantly, and to the pro-
portionally greater exclusion of the proper constituents of the fibres :
but the characters of fatty degeneration are rarely, if ever, so well
marked in the fibres of voluntary muscles as in those of the heart*
In the examination of different examples of fatty degeneration of the
voluntary muscles, you may find much diversity in the tissue between
* There has been some speculation amongst pathologists respecting the part of the fibre
in which the fatty change commences. Some have supposed that the fibrillae, or sarcous
elements, become gradually converted into fat-granules. The opinion, however, appears
to be now gaining ground that the disposition of fatty particles takes place, in the first in-
stance, between the fibrillee, around the nuclei, or cells, within the fibre itself. See espe-
cially, Bottcher, in Virchow's Archiv, 13ih vol. p. 227, 1868, and CO. Weber Die En-
twicklung des Eiters. Virchow's Archiv, 15th vol.
100 ATROPHY OF
the fibres and fasciculi. In some instances, the interspaces between
the fasciculi are filled with connective tissue, both more abundant and
tougher than that in healthy muscle ; so that it may be hard to dissect
the fibres for the microscope. With this there may be no unusual
quantity of fat ; but, in other cases, the quantity of fat between the
fibres is very great, and the fibres themselves may seem empty, or
wasted, as if overwhelmed by the fat accumulating around them. In
such a case, when the accumulating fat has coalesced with that which
before surrounded the whole muscle, it may be difficult to find where
the muscle was ; for the whole of what belonged to it, after its degenera-
tion, may be gone, and in its place there may remain only an obscure
trace, if any, of fibrous arrangement, dependent on the position of the
principal partitions of the new fatty tissue.
I cannot yet speak positively in explanation of this diversity in the
state of parts between the fibres. But, I think, the increase and tough-
ness of the connective tissue (when it is not the product of organized
inflammatory deposit) exist only in atrophied muscles which have had
to resist stretching, after the manner of ligaments; as, for example,
when their antagonists are not as powerless as themselves. And the
increase of fat seems to be found only when a muscle has been very long
atrophied, and has remained completely at rest ; then, the fibres them-
selves, after degenerating, may be removed, and give place to a forma-
tion of common adipose tissue, which collects in every part that they
are leaving, just as it does about shrinking kidneys, some cancers of
the breast, old diseased joints, and other parts similarly circumstanced.
In either case, we must distinguish between these formations of fat
outside, and those within, the fibres ; the former are in no necessary
connection with the proper atrophy of the fibres, but generally appear
subsequent to it ; and when they attain their highest degree, they are
not to be regarded as degenerations of the muscular tissue ; for they
are not, in any sense, formed out of it, though they occupy the .place
from which it was removed. This external, or interstitial, formation
of fat possesses the structure of adipose tissue, for the fat is contained
in cells, which present the well-known characters of fat-cells. These
cells are developed in the connective tissue, which lies between the
fibres.
The condition in which atrophy of the voluntary muscles most com-
monly ensues is inaction. Whenever muscles lie long inactive, they
either waste or degenerate : and this, whether the inactivity depend on
paralysis through affection of the nervous centres, or fibres, or fixity of
the parts they should move, or on any other cause. The degenerative
process may be so rapid that, in a fortnight, muscles paralyzed in
hemiplegia may present a manifest change of color : but it is com-
monly a much slower process.
The course of events in these cases appears to be, that the want of
exercise of a muscle, whether paralyzed or fixed at its ends, makes its
VOLUNTARY MUSCLES. 101
due nutrition impossible ; and the atrophy thus brought about is the
cause of loss of irritability of the muscle, i. e. of loss of its capacity for
contracting. For the experiments of Dr. John Reid* show that loss of
contractile power in a paralyzed muscle is due, directly, to its imperfect
nutrition, and only indirectly to the loss of connection with the nervous
centres. When he divided the nerves of a frog's hind legs, and left one
limb inactive, but gave the muscles of the other frequent exercise, by
galvanizing the lower end of its divided nerve, he found (to state the
case very briefly) that at the end of two months the exercised muscles
retained their weight and texture, and their capacity of contraction ;
while the inactive ones (though their irritability, it might be said, had
not been exhausted by exercise) had lost half their bulk, were degene-
rate in texture, and had also lost some of their power of contracting.
In other cases, too, he found the loss of proper texture always ensuing in
the inactive state, before the power of contraction was lost.
It is doubtless the same in man. A muscle which, by no fault of its
own, but through circumstances external to itself, has been prevented
from acting, soon becomes incapable of acting even when the external
obstacles to action are removed. Hence we may deduce a rule which
ought to be acted on in practice. When a person has had hemiplegia,
one commonly sees that long after the brain has, to all appearance, re-
covered its power, or even through all the rest of life, the paralyzed
limbs remain incapable of action, and as motionless as at the first at-
tack. Now, it is not likely that this abiding paralysis is the conse-
quence of any continuing disease of the brain ; rather, we must ascribe
it to the imperfect condition into which the muscles and nerve-fibres
have fallen during their inaction. So long as the state of the brain
makes voluntary action impossible, the cord, nerves, and muscles, are
suffering atrophy ; then, when the brain recovers, they are not in a
state to obey its impulses, because they are degenerate ; and thus, their
inaction continuing, they degenerate more and more, and all remedy
becomes impossible. If this be true, Dr. Reid's experiments suggest
the remedy. When muscles are paralyzed through affection of the ner-
vous system, we ought to give them artificial exercise : they should be
often put in action by electricity or otherwise ; their action, though
thus artificial, will insure their nutrition ; and then, when the nervous
system recovers, they may be in a condition ready to act with it.
You will find this suggestion ingeniously supported by my friend Mr.
W. F. Barlow, in a paper published by him in the " Lancet.'' In one
case, in which I could act upon it, the result was encouraging. A little
girl, about eight years old, had angular curvature and complete loss of
voluntary movement in the lower extremities. This had existed some
weeks, but as I found she had reflex movements, the legs twitching in
a very disorderly way as often as the soles were touched, I advised that
* Edin. Monthly Joaro. of Med. Science, May, 1841. See also, M. Brown-S^quard, in
the Gsz. Medicale, No. 9, 1850.
102 ATROPHY OF
the limbs should be put in active exercise, for about an hour two or
three times a day, by tickling the feet, or in some similar way. The
result was, that when, several weeks afterwards, the spinal cord re-
covered, and she could again direct the effort of the will to the lower
limbs, the recovery of strength- was speedy and complete ; more so, I
think, than if, in the paralyzed condition, the muscles and nerves had
been left to the progress of the atrophy. A similar paralysis, about two
years later, occurred again, and was similarly recovered from.
The hindered action of muscles, though the most frequent, is not the
only condition from which their atrophy may ensue. They waste,
together with all the rest of the body, in most emaciating diseases ; as,
for example, in phthisis : and they may degenerate into fat, in concert
with other tissues, in a generally defective nutrition.
But, besides the general atrophies of muscles, a similar affection oc-
curs sometimes as a primary or spontaneous affection of one or more
muscles. We find sometimes one of the muscles of an extremity, or of
the back, thoroughly atrophied, while the others are healthy ; and no
account can be given of its failure : or we may even have in the same
muscle limited patches of degenerated structure separated by inter-
vening healthy tissue. Thus, it is not very unfrequent to find a portion
of the lower and posterior part of the recti abdominis muscles in a state
of fatty degeneration, and the same may be occasionally seen in portions
of the deep muscles of the back.
Rokitansky* briefly refers to a spontaneous fatty degeneration of
the muscles of the calf attended with extreme pain : Mr. Mayof has
recorded two cases of apparently spontaneous atrophy of the muscles of
the shoulder, in which, in a few weeks after severe pain, but no other
sign of acute inflammation, all the muscles about the shoulder became
simply, but exceedingly, atrophied ; and still more recently, Dr. Bauer^
has related a case in which pain in, and contraction and wasting of, the
muscles of the calf followed a stab in the back near the spine.
We name these spontaneous atrophies, and it may be that the defec-
tive nutrition is the first event in the abnormal chain ; but, I think, we
shall hereafter find that, in most of them, the degeneration is a part of
some inflammatory process ; for, as I shall have to describe in future
lectures, there is no tissue in which it is more evident than in the
muscles, that a degeneration of the proper elements of an inflamed part
is associated with the more obvious effects of inflammation.§
Atrophy of the muscular substance of the heart may, like that of
* Pathol. Anat. B. 2, S. 348. t Outlines of Human Pathology, 1836 ; p. 117.
J On Hip Diseases, New York, 1859.
§ Virchow has recorded in his Archiv, vol. xiii, p. 266, 1858, two cases of pericarditis,
in which there was fatty degeneration of the muscular fibres of the heart. The degenera-
tion was much more strongly marked in those fibres which were nearest the outer surface,
and gradually diminished in the deeper parts. From these circumstances he is of opinion
that in these cases the fatty metamorphosis was a consequence of the pericarditis.
THE HEART. 103
which I have just been speaking, appear in either wasting or degenera*
tion, or in a combination of the two. Of the former I mentioned
examples in the beginning of the lecture, in the heart of a cancerous
man, fifty years old, which weighed only five ounces four drachms ; and
that of a diabetic woman, twenty-two years old, which weighed only
five ounces one drachm. Both these had deviated from the general
rule of enlargement of the heart with advancing years, in adaptation
to the diminished quantity of blood, and the general diminution of the
body.
In these cases there is a u^iiform decrease of the heart : its cavities
become small, and its walls proportionally thin ; and the fat on its ex-
terior diminishes, or is changed into a succulent, oedematous tissue. In
other instances the cavities are dilated, without proportionate thicken-
ing, or, it may be, even with thinning of their walls. This, probably,
occurs chiefly in cases of such increased obstacles to the circulation as
might, in other persons, or in other conditions, engender hypertrophy
of the heart. Or, the dilatation may be the consequence of wasting in
a heart that was once large and strong.
But, an atrophy of the heart much more important than any of these,
is that which consists in fatty degeneration.
Extreme instances of fatty degeneration of the heart have been long
known. The whole, or the greater part of the heart, in such cases, may
seem reduced to fat ; the degenerate tissue having coalesced with that
which lies on its surface, and the degeneration being accompanied by
thinning and softening of the walls.
In like manner, the cases have been well known and described for
which Dr. Quain proposes the name of "fatty growth,'* to distinguish
them from the "fatty degenerations" of the heart. In these, the
adipose tissue accumulates in unusual quantity on those parts of the
exterior of the heart in which it naturally exists, and is found, though
often emaciated and very soft, even in the thinnest people, viz., along
its transverse furrows, the furrows in which the coronary vessels run,
and others. From these positions, the fat dipping more and more
deeply may nearly displace the fibres, and may lead to a secondary
degeneration of them ; but, commonly, the heart's fibres are themselves
healthy, even when they lie completely imbedded in the overgrown fat.
But these conditions, and their combinations, are too well known to
need that I should describe them, or refer particularly to any speci-
mens of them, except to a sheep's heart, which is in the College
Museum (No. 1529), and which shows, in an extreme degree, a method
of the growth of fat which is rarely imitated, in even a trivial measure,
in the human subject. It exhibits a great accumulation of fat on its
surface, and its walls are thin ; but the greater parts of the cavities of
the ventricles and of the left auricle are occupied by large lobulated
growths of suet-like fat. The weight of the fat here added to the heart
is 25 ounces, and it is said that there was also a large accumulation of
104 ATROPHY OP
fat about the kidneys. But no other history of the ease is extant than
that the sheep was inactive, and had dyspnoea on exertion.
These cases of extreme fatty growth, or of extreme degeneration, of
the heajt are much rarer than those of which I have now to speak.
The most common form of fatty degeneration is that in which you
find, on opening the heart, that its tissue is in some degree paler and
softer than in the natural state, and lacks that robust firmness which
belongs to the vigorous heart. But what is most characteristic is, that
you may see, especially just under the endocardium, spots, small
blotches, or lines, like undulating or zigzag transverse bands, of pale,
tawny, buflF, or ochre-yellow hue, thick-set, so as to give, at a distant
view, a mottled appearance. These manifestly depend not on any de-
posit among the fasciculi, but on some change of their tissue. For, at
their borders, you find these spots gradually shaded-off, and merging
into the healthy color of the heart ; and when you examine portions of
such spots with the microscope, you never fail to find the fatty degene-
ration of the fibre.
The yellow spotting, or transverse marking of the heart, may exist in
the walls of all its cavities at once, or may be found in a much greater
degree in one than in the others. It may exist in all parts of the
thickness of the walls, or may be chiefly evident beneath the endo-
cardium and pericardium. It is far less common in the auricles than
in the ventricles ; and when it exists simultaneously in all parts it is
less advanced in the auricles. It is more common in the left ventricle
than in the right ; and in the left ventricle it is commonly most ad-
vanced on the smooth upper part of the septum, and in the two large
prominent fleshy columns. Indeed, it may exist in these columns
alone ; and when, in such a case, the rest of the heart remains strong,
may account for the occasional occurrence of rupture of the columns.
These yellow spottings of the heart, produced by degeneration of
scattered portions of its fibres, are, as I have said, the most evident,
as well as the most frequent, indications of its degenerative atrophy.
But a similar afiection may exist in a worse form, though it be less
manifest : worse, because the degeneration is more extensive and more
uniform ; and less manifest, because it is less distinctly visible to the
naked eye, and must be recQgnized by the touch rather than by the
unaided sight. The whole heart feels soft, doughy, inelastic, unresist-
ing ; it may be moulded and doubled-up like a heart beginning to de-
compose long after death : it seems never to have been in the state of
rigor mortis. These conditions are more manifest when a section is
made through the wall of the left ventricle. Then, if the wall be only
partly cut through, the rest of it may be very easily torn, as if with
separation of fibres that only stick together ; and the cut surface of the
wall looks, as it were, lobulated and granular, almost like a piece of
soft conglomerate gland, an appearance which is yet more striking when
observed with a simple lens of about half an inch focus. In color, the
THE HEART.
105
heart has not ou its surface, much less on its section, the full ruddy
brown of healthy heart, a color approaching that of the strong volun-
tary muscle; but is, for the most part, of a duller, dirtier, lighter
brown, in some parts gradually blending with irregular marks or
blotches of a paler fawn, or dead-leaf color.
These appearances of the degenerate heart may be variously mingled ;
and they may be variously associated with overgrowths of the external
fat, or with previous hypertrophy or other changes of structure in the
heart. But, however much the appearances of the affection may be
obscured, the general characters of softness, paleness, mottled color,
and friability, will be sufficient, if not always to prove, yet always to
excite suspicion, that the fatty degeneration of the heart exists : and,
if only suspicion is excited, the microscopic examination may be always
decisive. The chief microscopic appearances are delineated in the
subjoined sketch.
When a portion of the heart's walls, especially if they are very soft,
is dissected in the ordinary way, with needles, for the microscope, the
Shres are broken into short pieces, some twice, some five or six times,
as long as they are broad. The broken ends of these short pieces are
usually squared ; but some are round, or irregular, or cloven, and
broken off lower down. The pieces are almost always completely
separated, having no appearance of even cohering at their sides, and
they lie scattered disorderly.
In whichever form the degeneration is examined, you may find that,
in some pieces, the transverse stride are still well seen and undisturbed,
Pig. 6 •
appearing quite as in health. In more, they are interrupted or ob-
scured by dark dots, or by glistening particles with shady_ black mar-
gins, like minute oil-particles scattered without order in the fibres.
n heart; i, early stage; I*, n
106 ATROPHY OF
Where such particles are few, they appear to lie especially, or only, in
contact with the interior of the sarcolemma ; but, where more numer-
ous, they appear to occupy every part of the fibre, leaving the trans-
verse striae discernible only at its margins, or even completely obscuring
or replacing them, and making the fibre look like a gland-tube filled with
dark granules and larger glistening dark-edged fat-particles. Where
these particles are very numerous in a fibre, they appear also generally
larger, and more generally glistening and black-edged, like larger oil-
particles.
There may be no oil-drops floating about ; no fat-cells ; scarcely
even any of the minute particles, which are seen in the fibres, may
appear out of them ; the field of the microscope may be perfectly clean.
In these minor respects, however, many differences exist; though I
think it may be stated that the degeneration is very rarely, if ever,
accompanied by any morbid product deposited between the fibres;
whatever fatty matter may appear between them, is only such as has
escaped from them.
As a general rule, the palest parts of the heart are most advanced in
the disease ; but even in microscopic portions some pieces of fibres
appear hardly changed, while those all round them are completely
granular.
I alluded, in the last lecture, to the defective condition of the nuclei
of degenerate elemental structures. This is peculiarly well shown in the
degenerate fibres of the heart. When those of a healthy heart are
placed in diluted acetic acid, they display a longitudinal series of nuclei,
at nearly equal distances apart, and usually lying in the middle of the
presenting surface of the fibre. Nuclei of this form are, so far as I
know, peculiar to the heart-fibres. They are large, reddish-yellow, like
blood-globules, especially when the heart is very robust : they are
elongated, oval, or nearly quadrilateral ; and at each of their ends one
almost always sees tapering groups of small, isolated, yellowish gra-
nules, like particles separated from them, and gradually withering. But
in the degenerate fibre, when the change is least advanced, the outlines
of the nucleus look dim, and it loses its color : when the change has
made further progress, the nucleus cannot be seen at all, though its
former place may be indicated by some of the narrow group of gra-
nules ; and in a yet later stage, when the sarcolemma appears nearly
full of fatty particles, all trace is lost alike of the nucleus and of the
granules.
I have spoken of fatty degeneration of the heart at this great length,
both because there is no better example for illustration of the general
pathology of such affections, and because it is extremely important that
this condition of the heart should be recognized after death, even when
no suspicion could be entertained of it during life. For it often intro-
duces unexpected dangers into the ordinary practice of surgery : it is,
I believe, not rarely the cause of sudden death after operations ; it is
THE HEART. 107
one of the conditions in which chloroform should be administered with
more than ordinary caution. They who labor under ii may be fit for
all the ordinary events of calm and quiet life, but they are unable to
resist the storm of a sickness, an accident, or an operation. And let it
not be said that one learns little in learning too late the existence of an
incurable disease ; for very often the death that has come from such a
disease has been ascribed to a wrong cause, and has spoiled confidence
in good men and their good measures. Nor does the caution seem un-
necessary that, serious as the effects of the disease are, the change of
structure may escape any but a very careful and practised examiner.
For, often, the change is hardly manifest to the eye, though, while it
affects the whole heart, it may have destroyed life.*
Atrophy of the organic or smooth-fibred muscles, doubtless occurs,
as a simple decrease of them, in the thinning of the coats of the intes-
tines, stomach, and other hollow organs, which is sometimes associated
with general emaciation, or with diminished function : but the change
has not been carefully studied. Of the fatty degeneration of this mus-
cular tissue, examples are described in the muscular coats of the arte-
ries, f which partake in the corresponding change, or atheromatous
affection, of their thickened internal coats ; in the coats of the urinary
bladder ;% and in the uterus.§ In the latter organ the change has pe-
culiar interest; taking place, as it does, quickly after the fulfilment of
office in parturition : affecting all the muscular fibro-cells which, during
gestation, had been developed to their perfection ; and preceding their
absorption and replacement by new-formed fibro-cells, like those which
existed in the young and unimpregnated uterus. The series of changes
thus traced by Kilian tell a complete history of nutrition, in the suc-
cession of development and growth to perfection, of discharge of func-
tion, consequent degeneration, absorption, and replacement by new
structures that, in their progress, pass through the same phases as
their predecessors. The production of fat in the uterine tissue confirms
also the probability which I have already mentioned (p. 60), that fat is
one of the Usual results of the chemical change which takes place in
muscular action, and is, in this relation, a substance, like the kreatine.
* Wheu the lecture was delivered in 1847, I related some cases of sudden death from
this affection ; and expressed the hope that its whole clinical history would be traced by Dr.
Ormerod, who helped me very much in investigating its morbid anatomy. The hope has
been fulfilled far beyond my expectation by both him and Dr. R. Quain, who was, at the
same time, actively occupied with a similar course of inquiry. I may therefore refer the
reader to their essays, in the Medical Gazette for 1849, vol. ii; and in the Medico-Chirurgi-
cal Transactions, vol. xxxiii ; essays, valuable alike for the importance of their facts, and for
the thoroughly scientific spirit in which they are conceived.
f Rokitansky, Pathol. Anat., ii, p. 543; Kolliker, Zeitschr. fDr wissench. Zoologie, i,
p. 81.
X Mr. Hancock, as quoted by Mr. Barlow, Med, Timet and Gazette^ May 15, 1852.
} Kolliker, 1. c. p. 73. Kilian, in Henle and Pfeufer s Zeitschr. fQr rat. Medicin, vols.
viii and ix.
108 ATROPHY OF
which is also found in the uterine tissue after birth,'*' intermediate and
transitional between the proper constituents of the tissues and the oxi-
dized materials of excretions. It may be added, that the w^hole sub-
stance of the uterus and its membranes partakes of the degenerative
change, and that the removal of the old tissues and the formation of
new ones is so total, that, as it has been justly said, a person has a new
uterus after each delivery. But the peculiarity of the case is only in
that the change is accomplished quickly, manifestly, and simultaneously
in a large mass of tissue : in the same sense, though at unknown times,
men have often new hearts, new glands, and new brains.
In the bones we may probably consider that a calcareous degenera-
tion occurs as a method of atrophy, in addition to those just described
in the muscles : for to such a degeneration we may ascribe the increased
proportion of bone-earths in the skeletons of aged persons. The aug-
mentation of earthy constituents is not attended with increased strength
of the bones : rather, they become, in old persons, thin-walled, and
more easily broken ; the change being commonly associated with both
wasting and fatty degeneration, and the whole tissue being rarefied. It
is through this general want of compactness in their construction that
old bones are weak : for, as Dr. Stark's analyses show very well, the
strength of bones depends more on their compactness than on the pro-
portion of their constituents.
I am not aware that any analyses of diseased or other bones have
show^n a calcareous degeneration of them, except in old age : but its
frequent occurrence is highly probable. The other modes of atrophy
may be more fully illustrated in the two forms already often referred
to. The simple wasting of a bone is a common change. Examples
have been already adduced in connection with the subject of unequal
length of the limbs (p. 78), and with that of the effects of pressure (p.
80), as well as in relation to the general history of atrophies. Among
many specimens in the College Museum, the most striking is the skele-
ton of a hydrocephalic patient from the collection of Mr. Liston (No.
3489). It is the more remarkable, because, while all the bones of the
trunk and limbs are reduced, by atrophy, to exceeding thinness and
lightness, the bones of the cranium are as exceedingly enlarged in
adaptation to the enormous volume of their contents.
Another interesting specimen is a skull (No. 8) fitted up by Hunter
to show the movements of the edentulous lower jaw, as he has described
them in his " Natural History of the Teeth.'' It shows the atrophy
not only of the alveolar margins, but of every part of the jaws, and
even of their palatine parts, and those of the palate bones, which are
quite thin and transparent. f
* Siegmundf in the Wtirzburg Verhandlungen, B. iii, H. 1.
t But in the skulls of old persons the atrophy is not necessarily limited to the jaws and
other bones of the face. The cranial bones frequently participate, they become thin, and
THE BONES. 109
A rare specimen of atrophy of the lower jaw is shown in a case of
complete osseous anchylosis of both temporo-maxillary articulations,
from Mr. Howship's Museum (No. 966). Similar atrophy of bone in
its extreme state is illustrated by an example of anchylosis of the knee
(No. 384), from the case described by Mr. Thurnam.* Considerable
apertures are formed in the wasted walls of the femur and tibia, and they
were covered in by the periosteum alone : the whole thickness of these
portions of the walls having been removed in the progress of the atro-
phy. In the Museum of St. Bartholomew's is a specimen in which
simple atrophy of the femora led to such fracture as, being effected by
a slight force, is called spontaneous. The atrophy of these bones oc-
curred coincidently with extreme emaciation of all the other parts, as
well as of the skeleton ; an emaciation which was to be ascribed, I be-
lieve, more to starvation than to anything else. The shafts of the
femora are exceedingly small, and their walls are so thin that, although
their texture appears healthy, they could not resist the force of the
muscles acting on the articular ends. They broke: and the result
shows a remarkable example of the capacity for repair of injuries even
while the process of ordinary nutrition seems almost suspended : for the
fractures were firmly reunited.
I might greatly multiply examples of such simple wasting atrophy
of bones ; but let these suflSce, that I may speak now of fatty degenera-
tion of the bones.
I have already said that it is common, in many atrophied bones, to
find an excess of fatty matter ; I referred to old bones laden with fat
as examples of a form of senile atrophy ; and sometimes, in cases of
diseased joints, the form of atrophy assumed by the disused bones is
that not merely of exceeding thinness of the walls and wasting of the
cancelli, but of an accumulation of soft fat, filling every interstice and
maintaining the size of the bone. But it is now to be added, that the
bones, like other organs, are liable to a fatty degeneration, which, be-
cause of the obscurity of its origin, we must be content to call spontane-
ous; and this fatty degeneration of the bones is the disease which most
English writers have described as Mollities Ossium.
The Museum of the College has a remarkably rich collection of speci-
mens of this disease : a collection embracing specimens from nearly all
the cases with whose histories we are most familiar.
aodergo a marked diminntion in weight. These changes have been CHrefnlly examined
by Virchow (Wfirzborg Verhandlung, B. iv, p. 354; Gesam. Abhandl. p. lOOO), and de-
scribed by him as a *' Malum senile." The old centres of ossification, as the eminences of
the parietal bones, are chiefly aflected. The wasting begins from without, thinning and
gradually removing the outer table, then the diploe, and at last, perhaps the inner table
itself. In some cases the diploe may hardly undergo any change, in others its lamellae fuse
togetber, and form a compact layer, so that it looks like an outer table. Along with this
thinning from without a formation of new bone may, at the same time, take place within
the skull.
* Medical Gazette, vol. xxiii, p. 119.
110 ATROPHY OF
Well-marked examples of the fatty degeneration are shown in No.
400. These are two femora fractured by a slight force, and, in their
dried state, light, very greasy, mahogany-brown, and so soft that you
may crush many parts of them with the fingers. Their excess of fat
is evident ; but no more of their history is known than that they came
from an elderly, if not an old, man, — an Archbishop of Canterbury.
In No. 398 is a section of a humerus, affected as many other bones
of the same person were, with extreme fatty degeneration ; and the
Catalogue contains, with its description, a reprint of an essay, by Mr.
Hunter, which escaped even the careful research of the editor ef his
works, Mr. Palmer. His essay is entitled, " Observations on the Case
of Mollities Ossium described,** &c., by Mr. Goodwin, in the "Lon-
don Medical Journal.'** It was communicated in a letter to Dr.
Simmons, the editor of that journal ; and I will quote one passage, to
show both what was the original appearance of the bones, and how
completely Mr. Hunter's description confirms the opinion that this
mollities ossium was really a fatty degeneration of the bones. He says,
speaking of this humerus, " The component parts of the bone were to-
tally altered, the structure being very different from other bones, and
wholly composed of a new substance, resembling a species of fatty
tumor, and giving the appearance of a spongy bone, deprived of its
earth, and soaked in soft fat.**
Nothing can better express the character of the change, or its simi-
larity to the fatty degenerations of other organs, in which we find the
proper substance of the part gradually changed for fat, and the whole
tissue spoiled, while the size and outer form of the part remain unal-
tered.
The same characters are shown in the often-quoted case by Mr.
Howship, of which specimens are preserved in Nos. 401-2-3. The
last of these specimens shows what remained of the upper part of a
femur after boiling ; scarce anything besides a great quantity of white
crystalline fatty matter.
It is the same with a femur (No. 403 B) presented to the Museum
by Mr. Tamplin, in the examination of which I first obtained, with the
microscope, the conviction of the nature of the change which constitutes
what we call mollities ossium. This has the same characters as the
specimens already shown, and the medulla of the bone had the bright
yellow, pink, and deep crimson hues, which are so striking in many
instances of the disease. But the constituents of this apparently
peculiar material were, free oil in great quantity ; crystals of marga-
rine, free, or inclosed in fat-cells ; a few fat-cells full of oil as in health,
but many more, empty, collapsed, and rolled up in strange and decep-
tive forms. The pink and crimson colors were owing to the bright
tints of a part of the oil-globules, and of the nuclei and granules in the
* Vol. vi, 1785.
THE BONES. Ill
collapsed fat-cells ; and there was no appearance whatever of an excess
of blood in the bone, or any of its contents.'*'
From this examination, therefore, as well as from all the other facts,
1 concur entirely in Mr. Curling's opinion respecting this disease.f A
specimen (No. 403 A) from the case on which he chiefly founded his
opinion, and which he has very accurately described, closely resembles
those I have referred to. He proposes the name " Eccentric Atrophy
of Bone" to express one of the principal characters of the disease; lEind
1 would have adopted it, as preferable to " Osteoporosis," under which
I think Bokitansky would include these cases, but that it seems desira-
ble to class this affection with others to which it bears the closest
analogy, by giving it the same generic name in the designation, fatty
degeneration of bones.
The cases above referred to included the principal examples of the
disease observed and recorded in England under the name of mollities
ossium up to the period of publication of the first edition of these lec-
tures ; and to these, I think, might be added the case described by
Mr. Solly ,J for the appearances presented by the femur (No. 403 C)
are strikingly similar to those in the specimens already referred to,
and the material filling its medullary cavity contained abundant fatty
matter. Since that time two additional cases have been recorded, one
by Dr. T. K. Chambers§ in a female, set. 26, in whom, so far as the
examination was conducted, not only the bones, but the muscles, had
undergone fatty degeneration ; and a second by Dr. Ormerod,|| which
occurred in an adult male, subsequently to the age of thirty, and
affected the skeleton generally.^
You might ask, then, what is the real mollities ossium ? or is there
such a disease different from what these specimens show ? I could not
* It shonld be stated, however, that Litzmann has described in the beginning of the
disease, the medulla as being very rich in blood, which is partly contained in the vessels,
and partly extravasated. He states that, on making a microscopic examination, numerous
unchanged blood-corpuscles, and abundant groups of brown-red pigment granules, may be
recognized. See his Beitrftge zur Kenntniss der Osteomalacie, translated by Dr. M. Dun-
can, in the Eld. Med. Jal., 1861-62. In this essay, Litzmann includes under the term
osteomalacia, the cases which have been described as mollities ossium, osteoporosis, eccentric
atrophy, roalakosteon. He regards the disease, whether it occurs in the male or female, in
the bones of the extremities, or those of the trunk, as the same.
t Med. Chir. Transactions, vol. xx.
^ Med. Chir. Trans., vol. xxvii. 2 Ibid., vol. xxxvii., 1S54.
II British Medical Journal, Sept. 1859.
f One may occasionally observe in the dissecting-room the ribs of old subjects sosoAened
that tbey may be easily bent in various directions without breaking. In these cases it may
be seen that the earthy matter has been more or less replaced by a soft, fatty substance.
Retzius has described and figured (Museum Anat. Holmiense, 1855) a very remarkable
craniam, the bones of which, especially at the base, were so infiltrated with a fatty deposit,
that considerable distortion, with great alterations in the size and shape of the various
cranial foramina, had taken place. Additional cases of mollities ossium occurring in Britain
have been recorded in the Edinburgh Medical Journal, August, 186*2, by Dr. W. C. Mcintosh,
of Perth, and in the Transactions of the Medico-Chirurgical Society of London, vol. xlv,
1862, by Dr. Robert Barnes.
112 ATROPHY OP
from my own observations answer such a question ; for I have never
seen a specimen which appeared to fulfil in any degree the general
notion of mollities ossium, as a disease consisting in the removal of the
earthy matter of bone, and the reduction of any part of the skeleton to
its cartilaginous base. I do not doubt the accuracy of what others
have written of such an affection ; but I am sure that the cases I have
cited are not simple softenings of bone, but fatty degenerations ; and
that those cases must be very different to which Rokitansky refers
under the names of Osteomalacia, Malakosteon, Knochenerweichung,
and Rachitismus adultorum. He gives, as a characteristic of the
disease, that it affects the bones of the trunk, or a part of them, much
more often, and more severely, than the bones of the extremities, and
occurs especially after child-bed. Now, in the cases which I have en-
deavored to illustrate, the extremities, not the trunk, are the chief seats
of the disease ; and there is no evidence of the fatty degeneration oc-
curring more often after delivery than in any other period or condition
of life. So that, on the whole, I think we may consider there are two
diseases included under the name of mollities ossium ; namely, the fatty
degeneration which these specimens show, and which seems to be the
more frequent in England; and the simpler softening of bone, or
rickets of the adult, to which Rokitansky 's description alludes, and in
which the bones are flexible rather than brittle, and appear reduced to
th^ir cartilaginous state. This affection seems to be more frequent
than the fatty degeneration in Germany and France ; and I think the
only probable well-recorded instance of its occurrence in England, is
that related by Mr. Dalrymple,* Dr. Bence Jones,t and Dr. Macintyre.J
I feel, however, that there is still much doubt respecting the relations
of these affections ; they are, perhaps, more nearly allied than, at first
sight, they may seem ; and I think some clue to their alliance may be
obtained from the relation which they both have to the rickets of the
young subject. The relation is best shown in the bones of the skull,
and is illustrated by specimens in the College Museum (Nos. 392 to 396,
and 2857 to 2860) ; but I need not now dwell on it while wishing to
give only a general account of the atrophies of bones.§
I can scarcely doubt that future inquiries will ascertain that, in every
tissue, changes such as these which I have described in muscle and in
bone are the results of simply defective nutrition. But I have neither
knowledge nor space for more than a few additional instances. Among
these, the degenerations of bloodvessels may be cited. The blood-
vessels of an atrophied part, I have already said, decrease in adapta-
* Dublin Journal of Med. Science, vol. ii, 1846.
t Philos. Trans., 1848. J Medico Cliir. Trans., vol. xxxiii.
§ I have minutely described the specimens here referred to, as well as the later changes
which the bones undergo, in the Pathological Catalogue of the College Museum, vol. ii, p. 22,
and vol. v, p. 7.
THE BLOODVESSELS. 113
tion to the part : they become less, till they can carry no more blood
than is just enough to meet the diminished requirements of nutrition :
and this they do, not by such muscular contraction as adapts them to
a temporary decrease of function in a part, but (if one may so speak)
by a diminishing growth. Moreover, when a part degenerates, its
bloodressels are likely to degenerate in the same manner. There are,
I think, instances in which fatty degenerations of bloodvessels have
occurred in consequence of similar change in the part that they supply.
But the more interesting examples are those of primary degeneration
of the bloodvessels. This has been long known in the atheromatous
disease, as it was called, of the larger arteries ; the true nature of
which, as a fatty and calcareous degeneration of the inner, and, con-
secutively, of the middle arterial coat,'was discovered by Mr. Gulliver.*
The descriptions of this affection by him, and by Rokitansky, and Vir-
chow, have left nothing unsaid that is yet known. Observations are
each year becoming more numerous and interesting of fatty degenera-
tion occurring even in the smallest bloodvessels. Such changes are
especially observable in the minutest cerebral vessels ; and their im-
portance, in relation to apoplexy, of which they seem to be the most
frequent precedent, as well as for the general illustration of the minute
changes on which the defective nutrition of organs may depend, will
justify, I hope, my repeating the description which I wrote from the
first instances in which they were observed, and has since, I think, been
sufficiently confirmed.f
In the least degrees of this affection, the only apparent change of
structure is, that minute, shining, black-edged particles, like molecules
of oil,J are thinly and irregularly scattered beneath the outer surface
of the small bloodvessels of the brain. Such a change may be seen
in the vessels of portions of the brain that appear quite healthy, as well
in the capillaries as in branches of both arteries and veins of all sizes,
from l-150th of an inch in diameter to those of smallest dimension.
As the disease makes progress, the oil-particles may increase in num-
ber till the whole extent of the affected vessels is thick-set with them,
and the natural structures, even if not quite wasted, can hardly be dis-
cerned. While their number thus increases, there is, also, usually, a
considerable increase of the size of many of the oil-particles, and they
may be seen of every size, from an immeasurable minuteness to the
diameter of l-2000th of an inch. In other places one sees, instead of
* Medico-Chirurg. Trans, vol. xxvi, p. 86. f Medical Gazette, vol. xlv.
J Dr. Jenner (Med. Times and Gaz., Jan. 31, 1862) has shown that these appearances of
oil-particles are very closely imitated by equally minute particles similarly deponited,
but which are proved to be calcareous by their solubility in hydrochloric acid. I think it very
probable that what I have here described as fatty or oily matter may oAen be, at least in
part, calcareous; we may reasonably expect this affection of the small vessels to be exactly
analogous to the common fatty and calcareous degeneration of the larger arteries, although
there is no generality of coincidence between them. I have also seen a pigmental degene-
ntioo of srnall oerebral arteries very similar to the fatty one described above.
t.
114 ATROPHY OP
this increase of scattered oil-particles, or together with it, groups or
clusters of similar minute particles, which are cpnglomerated, some-
times in regular oval or round masses, like large granule-cells, but more
often in irregular masses or patches, in the wall of a great part of the
circumference of a bloodvessel.
In a single fortunately selected specimen, one may see, in different
branches of a vessel, all these degrees or states of the degeneration, —
the less and the more thickly scattered minute oil-particles, the clusters
of such particles in various sizes and shapes, and the larger particles like
drops of oil.
When the degeneration has made much progress, changes in the
structure, and, not rarely, changes in the shape also, of the affected
bloodvessels may be observed. The chief change of structure appears
to consist in a gradual wasting of the more developed proper structures
of the vessels : growing fainter in, apparently, the same proportion as
the disease makes progress, the various nuclei or fibres are at length
altogether lost, and bloodvessels of even l-150th of an inch in diameter
appear like tubes of homogeneous pellucid membrane, thick-set with the
fatty particles. The structures of the vessels are not merely obscured
by the abnormal deposits ; they waste and totally disappear.
The changes of shape which the vessels may at the same time un-
dergo are various. Very commonly, the outer layer of the wall is
lifted up by one or more clusters of oil-particles, and the outline of the
vessels appears uneven, as if it were tuberous or knotted. Sometimes
the outer or fibro-cellular coat of the vessels is for some distance raised
far from the middle coat, as if it were inflated, and the space between
them contains numerous particles of oil. (But, perhaps, this raising
up of the outer coat is often produced by water being imbibed while
preparing the specimen for examination.) Sometimes, but I think
only in vessels of less than l-500th of an inch in diameter, partial
enlargements, like aneurismal dilatations, or pouches, of their walls are
found.
The vessels most liable to this disease are, I think, the arteries of
about l-300th of an inch in diameter ; but it exists, generally, at the
same time, in the veins of the same or less size. As a general rule
(judging from the specimens hitherto examined), the disease decreases
in nearly the same proportion as the size of the vessels, and the small-
est capillaries are least, if at all, affected. But there are many excep-
tions to this rule ; and it is not rare to find vessels of from l-2000th
to l-3000th of an inch in diameter, having parts of their walls nearly
covered with the abnormal deposits.
The principal and first seat of the deposits is, in arteries, in the more
or less developed muscular or transversely fibrous coat :* in veins, it is
* Virchow (Cellular Path. p. dC)) states that the fatty degeneration in these cases is
seated in the outermost layer of the internal coat. He considers that the fatty particles
occupy the position of the connective tissue corpuscles, which become ol^ured, or even
THS BLOODVBBBELS.
115
ID the corresponding layer, immediately within their external fibrous
nucleated coat ; in veseelB, whether arteries or veins, whose walls con-
sist of only a simple pellucid membrane bearing nuclei, the substance
of this membrane is the Brst seat of the deposits. In some cases, the
outer fibrous coat of both arteries and veins appears to contain abun-
dant fatty matter. But it Is seldom that, in an advanced stage of the
Pig. 7.»
Fig. 8.
affection, any of the several coats of a bloodvessel can be assigned 9s
its chief seat ; for even in large four-coated arteries they wholly waste,
and their remains appear united in a single pellucid layer, of which the
whole thickness may be occupied by the deposit.
The figures represent some of the most usual appearances of the de-
generation.
The cases in which these changes were first observed were cerebral
ipoplexies in which the hemorrhage appeared certainly due to rup-
ture of the wasted and degenerate bloodvessels. The probability of
?uch an event is evident ; ae it is, also, that the less sudden effect of
cnmplelply hidden, by iha fctiy ilegeneraiion of iheir siibswneo. Owing to Iheae cotpiisclea
beipg bnuicfa«i celli, a stellate aicangemenl or the fatly masses may be onen seen.
* Fig. 7. An artery, of l-SOOtb of an inch in diameter, and a biHnch given ftom it,
from a Mrflened corpuB Btiialiun. Numeiou* oil.pariiFles of Tarioua sizoa are tcBtlered in
die muscalar coat, liBpei of ibe tissue of wbicb appear in obacuie transverse marks.
Fig. 8. From the same pan, a Tein l-600ih of an inch in diamelar, with brancliea from
I-I200tb to l-ISOOth, and portions of cspiliariea. Scaiterpd oil-panicles, anil groiipa like
biokeo itregaiar granule-cells, are seen in the homogeneous pellucid walls of all die vessels.
Pig. 9. A vewelof l-600thofan incbindiameler,and anolherof 1-I800lh,wiih abrancli
of I-3OCKM1 oT an iochi Groups and scaiiered oil-paiijcles are thick-set in Ibe simple, pel-
bcid, roembnuxms walls.
116 ATROPHY OP
this condition of the vessels is likely to be a gradual degeneration of
the parts of the brain which they supply. The relation between organs
and their bloodvessels must in this respect be mutual : in the same
measure, though ^lot in the same way, as atrophy of an organ, whether
wasting or degenerative, induces a corresponding atrophy of its blood-
vessels, so will the imperfection of degenerate vessels lead to atrophy
of the part in which they are distributed.
I suppose that the minute bloodvessels of many other parts might
be often found thus degenerate, if we could examine them as easily as
we can those of the brain ; but I am not aware that any have been so
described except those of the eye, in the cases of arctts seniliSy to which
I shall presently refer, and those of the lungs and placenta. In the
lungs, Dittrich* has traced affections of the arteries which, he says, the
account I have given above exactly fits, and the consequences of which,
in pulmonary apoplexy, correspond with the cerebral apoplexies due to
rupture of the small bloodvessels of the brain.
Many facts of exceeding interest are known concerning" the degene-
rations of nervous tissues, but, as yet, they are rather fragments than a
continuous history.
First, in relation to the causes of degeneration, two are chiefly known ;
namely, defect of blood, and arrested function. Gases of softening of
the brain have been long recognized as the consequences of ligature, or
obstructive disease, of the carotid or other large arteries ; but they have
received a new interest from the discovery by Virchow, and indepen-
dently by Dr. Kirkes, of their frequency in consequence of the obstruc-
tion of healthy cerebral arteries by masses of fibrine carried into them,
after being dislodged from the valves of the left side of the heart or
from some part of the arterial system. In these cases, the extent of
softening nearly corresponds with the range in which the branches of
the obstructed artery are distributed : for, beyond the circle of Willis,
the anastomosis among the cerebral arteries, like that among the cardiac,
is not sufficient to carry a full supply of blood into a part from which the
main stream is hindered, though generally enough to prevent the com-
plete death or sloughing of the part.
Of the atrophy following diminished or abrogated function of nervous
parts I have already mentioned examples in the shrinking of the brain
in old people, in the wasting of the nerves of paralyzed or fixed muscles,
and in that of the optic nerve and tract in cases of blindness. To these
may be added the cases observed by Dr. Waller ;t who has discovered
that when a nerve is divided, its distal part, i, e., the portion between
the place of division and the place of distribution, the portion in which
the nerve-office can be no longer exercised, always suffers atrophy,
* Ueber den Laennecscben Lungen-infarktus. Erlangen, 1850.
f Pbilos. Trans., 1850, Part 2 ; and in tbe London Journal of Medicine, July, 1852.
THE NERVOUS TISSUES. 117
wasting and degenerating. The same atrophy ensues in the whole
length of any spinal nerve whose root is divided ; and in any system of
nerves through which, after injury of the spinal cord, reflex actions can-
not be excited. The change, in divided nerves, begins at the distal
extremities of the nerve-fibres, and gradually extends upwards in the
branches and trunk of the nerve; but is repaired if the divided portions
of the nerve be allowed to reunite. I need not say how great interest
these facts have in relation to the anatomy and physiology of the ner-
vous system: but it is equalled by those related by Dr. Turck,* which
may be used for ascertaining the functions of the several columns of the
spinal cord, and their relations to the different parts of the brain, in the
same manner as, by those of Dr. Waller, knowledge may be gained of
the course and distribution, and of the centripetal or centrifugal oflSce,
of the several nerves. The main fact discovered by Dr. Turck is, that
after diseases of parts of the brain or spinal cord there gradually ensues
a softening, as by atrophy, of those tracts or columns of the cerebro-
spinal axis, through which, in health, impressions were habitually con-
veyed from the diseased part. The same general truth is illustrated by
both these series of observations ; namely, that nerve-fibres, through
which, from whatever cause, nerve-force can be no longer exercised, are
gradually atrophied. The atrophy took place very quickly in the frogs
that were the subjects of Dr. Waller's experiments : commencing in
young frogs, during the summer, in from three to five days, and being
completed in from twenty to thirty days. But, in the human subject,
the process, reckoned by the observations of Turck, and those in which
I have examined nerves atrophied in paralyzed muscles, is much slower.
Changes in the spinal cord are not, he says, discernible in less than half
a year after the apoplexy or other affection of the brain of which they
are the consequence.
The changes in the nerve-fibres thus atrophied are minutely described
by Dr. Waller. At first, transverse lines appear in the intratubular
substance, indicating its loss of continuity ; then it appears as if divided
into round or oblong coagulated masses, as if its two component ma-
terials were mingled ; then these .are converted into black granules,
resisting the action of ether,' acids, and alkalies ; and, finally, these
granules are slowly and imperfectly eliminated. f
In the atrophies of the brain and spinal cord, whether from ob-
structed circulation or from hindered function, the chief changes that
are observed are, the liquefaction or softening of the whole substance,
* Ueber secundare Erkrankung einzelner RQckenmarkstrange. Wien, 1851.
f G. Walter has recently (Virchow's Archivs, 1861, vol. xx, p. 426) re-examined the
changes which take place in nerve-fibres after division. He distinguishes the following
stages: 1st. Coeguiation of the medullary substance in the nerve-fibre. 2d. Resorption of
the preexisting contents of the medullary sheath. 3d. Fatty degeneration of the nuclei of
the nerre sheath. 4th. Resorption of the axial cylinder, after cracking and breaking up
into granules.
118 ARCUS SENILIS.
the breaking up of the nerve-fibres, and the production of abundant
granule-cells, or masses, and free-floating granules. Until very re-
cently there was a difficulty in accounting for the origin of these
granule-cells, on the supposition that they were cells undergoing fatty
degeneration, as it was thought that no cell-structures existed in the
white part of the brain and spinal cord. But the discovery by Virchow
in the great nervous centres of the delicate intermediate form of con
nective substance, termed by him Neuroglia, in which numerous small,
delicate, corpuscles are imbedded, and the observations by Lockhart
Clarke and others on the existence of a fine network of connective
tissue (in which multitudes of fine cells and nuclei are interspersed)
between the fibres of the columns of the cord, supply us with a source
from which these fat-containing granule-cells may be derived. *
The last example of atrophy of which I will speak is that which is
manifested in the Arcus senilis, — the dim grayish-white arches or ellipse
seen near the borders of the cornea in so many old persons. Its na-
ture, as a true fatty degeneration, consisting in the accumulation of
minute oil-drops in the proper tissue of the cornea, was discovered and
is fully described by Mr. Canton.f By his and others'J investigations,
it has also acquired a larger interest, in being found the frequent con-
comitant and sign of more widely extended degenerations that are not
within sight during life. Thus, it is commonly associated with fatty or
calcareous degeneration of the ophthalmic artery ; with fatty degenera-
tion of the muscles of the eyeball ; and, especially in old persons, with
fatty degeneration of the heart and many other organs. In short, the
arcus senilis seems to be, on the whole, the best indication that has
been yet found of proneness to an extensive or general fatty degenera-
tion of the tissues. It is not, indeed, an infallible sign thereof; for
there are cases in which it exists with clear evidences of vigor in the
nutrition of the rest of the body ; and there are others in which its
early occurrence is due to defective nutrition consequent on purely
local causes, such as inflammatory affections of the choroid, or other
parts of the eye : but, allowing for these exceptions, it appears to be
* The Editor can speak from his own observations of the existence in great numbers oi
minute corpuscles between the fibres of the white substance of the different divisions of the
encephalon, which corpuscles evidently belong to and form a part of the delicate inter-
mediate nerve connective tissue or neuroglia. The great abundance of these corpuscles not
only supplies a sufficient source for the production of granule-cells, but also for those forma-
tions of the corpuscles of pus, cancer, and tubercle, which are occasionally met with in the
midst of the white substance of the great nerve centres. For a fuller exposition of the
theory of the formation of such corpuscles from pre-existing tissue elements, the Editor may
refer to a lecture which he delivered before the Royal College of Surgeons of Edinburgh,
February 27, and which is published in the Edinburgh Monthly Medical Journal,
April, 1863.
t Observations on the Arcus senilis, in the Lancet, 1850 and 1851. •
X Especially Drs. Quain, Williams and Virchow (Archiv, B. iv, 288).
BEPAIR ETC. OP INJURED AND LOST PARTS. 119
the surest, as well as the most visible, sign and measure of those pri-
mary degenerations which it has been the chief object of the last two
lectures to describe.*
LECTURE VII.
GENERAL CONSIDERATIONS ON THE REPAIR AND REPRODUCTION OF
INJURED AND LOST PARTS.
Among the general considerations that may be suggested bj the pre-
ceding lectures, none, perhaps, is more worthy of earnest thought, than
that of the capacity of adaptation to the variety of their circumstances,
which is displayed by the several parts of the body. Each part may
be said to be conformed, in its first construction, to a certain standard
of measure, weight, and power, by which standard it is adjusted to the
other parts of the whole organism. The first perfection of the economy
is in the justness with which its several parts are thus balanced in their
powers ; and the mutual adaptation thus established is continued, in or-
dinary life, by the nutrition of each part being regulated according to a
law of direct proportion to the quantity of work that each discharges.
* Tbe degenerations of organs not described in the lectures, and the authorities not
already quoted, may be studied by the following references :
Arteries, Testicles, Lungs, and Liver : Gulliver, in Med. Chir. Trans., xxvi, p. 80.
Liver: Bowman, in Lancet, 1841-2, vol. i, p. 560.
Kidney : Johnson in Med. Chir. Trans, xxix, p. 1 ; with Appendix, in xxx, p. 182 ; Si-
mon, in Med. Chir. Trans., xxx, p. 141 ; Virchow, in his Archiv, B. iv, p. 264, et seq. ; and
Gairdner, Pathology of the Kidney, Edinb., 1848.
Colorless blood-cells, various Epithelial cells. Cartilage-corpuscles, Nerve-cells : Virchow,
in his Archiv, i, p. 144, et seq.
Langs : Bainey, in Med. Chir. Trans., vol. xxxi, p. 297.
Placenta : Barnes, in Med. Chir. Trans., xxxiv and xxxvi, and Druitt, Med. Chir. Trans.,
vol. xxxvi.
Placentl^ Decidua, and other tissues of the uterus, as well as the Muscular: Kilian, as
quoted at p. 131.
Cartilage: Redfern, " Anormal Nutrition in the Articular Cartilages," 1850; and Virchow,
in his Archiv, B. iv, p. 289. C. O. Weber, Virchow's Archiv, B. xiii, 1858.
Numerous calcareous degenerations: Dusseau, Het Beenweefsel en Verbeeningen, Am-
sterdam, 1850.
The Transactions of the Pathological Society of London abound in records of cases of fatty
and calcareous degenerations of and in the different textures.
Pigmental degenerations: Virchow, in his Archiv, B. i.
Prostatic Concretions: Hassall, Microscopic Anatomy. Wedl, Pathological Histology.
Amyloid Degeneration : Pagenstecher Ueber die Amyloide Degeneration. WOrzburg,
1858. FOrster, Atlas der Path. Anat, 1859. Rouget in Brown-S4quard's Jal. de la Phys.
Jan., 1850. T. G. Stewart, On the Waxy or Amyloid Degeneration of the Kidney. Ed.
Med. Jal., 1861.
The chief general histories of degenerations are by Rokitansky, Pathol. Anat. ; C. J. B.
WiUiarai, Principles of Medicine ; and Virchow, in the places cited above, and in his
Archiv, B. iy, p. 394.
The degenerations of products of disease will be described in future lectures.
120 GENERAL CONSIDERATIONS ON THE REPAIR AND
But when the external conditions of life vary, and require for the main-
tenance of health, varying amounts of function to be discharged by one
or more parts; and, still more, when disease disturbs the . functional
relations of any part to the rest ; then each part displays a capacity of
adaptation to the new conditions in which it is placed : each can assume
a less or greater size and weight ; each can acquire a less or more
powerful tissue ; each can thus rise above, or descend below, its stan-
dard of power.
This capacity of adaptation is shown in a yet more remarkable man-
ner in the recovery of parts from the effects of injuries and diseases. It
is surely only because it is so familiar, that we think lightly, if at all, of
the fact that living bodies are capable of repairing the effects of injury,
and that in this capacity they prove themselves adapted for events of
which it is not certain whether they will ever occur to them. The
exact fitness of every part of a living body for its present oflSce, not as
an independent agent, but as one whose work must be done in due pro-
portion with many others concurring in operation with it, is a very
marvellous thing; but it seems much more so, that in the embryo, each
of these parts was made fit for oflSces and relations that were then
future : and yet more marvellous than all it seems, that each of them
should still have capacity for action in events that are not only future,
but uncertain ; that are indeed possible, yet are in only so low a degree
probable, that if ever they happen they will be called accidents.
Let us have always in mind this adaptation of the living body to future
probabilities, while we consider the physiology of repair. If it be fairly
weighed, every part of the process of repair will be an argument of
divine design ; and such an argument as cannot be impugned by the sus-
picion that the events among which each living thing is cast have deter-
mined its adaptation to them : for all the adaptations here noted prove
capacities for things future, and only not improbable.
And let us also keep in view how the reparative processes may illus-
trate the laws of ordinary nutrition ; and especially observe that they
furnish evidence of the nature of the formative force exercised in the
complete organism. I mentioned in a former lecture (p. 61) that, in
many instances of repair and reproduction, the formation of the new
replacing structures cannot be ascribed to an assimilative force, or to
the development of tissue-germs derived from the injured or lost parts.
The completeness of repair after injury, and the extent to which it is
sometimes accomplished, become thus most striking evidences of the
principle that the formative force, and those that co-operate with it, are,
in the completed organism, the same and continuous with those which
actuated the formation of the original tissues, in the development of the
germ and embryo. There is in every considerable process of repair a
re-making of a part : and the new materials assume the specific form and
composition of the part that they replace, through the operation of no
other, or otherwise directed, force, than that through which that part
REPRODUCTION OP INJURED AND LOST PARTS. 121
was first made. For, in all grave injuries and diseases, the parts that
might serve as models for the repairing materials to be assimilated to,
or as tissue-germs to develop new structures, are lost or spoiled ; yet
the effects of such injury and disease are recovered from, and the right
specific form and composition are regained. In all such cases, the re-
produced parts are formed, not according to any present model, bu* ac-
cording to the appropriate specific form ; and often with a more strikingly
evident design towards that form as an end or purpose, than we can
discern in the natural construction of the body.
Moreover, it will be observed in the instances of repair of injury,
even more plainly than in the maintenance of the body in the successive
ordinary stages of its life, that the law of formation is at each period of
life the same : that every part is formed after the same method as was
observed in the corresponding part of the parent at the same period of
life. Thus, when, in an adult animal, a part is reproduced after injury
or removal, it is made in conformity, not with that condition which was
proper to it when it was first formed, or in its infantile life, but with
that which is proper according to the time of life in which it is repro-
duced ; proper, because like that which the similar part had, at the
same time of life, in members of former generations. In the reproduc-
tion of the foot or the tail of the lizard, they grow, as it were, at once
into the full dimensions proper to the part, according to the age of the
individual. Spallanzani expressly mentions this : that when a leg is
cut from a full-grown salamander, the new leg and foot are developed,
as far as form and structure are concerned, just as those of the larva
were ; but as to size, they from the beginning grow and are developed
to the proper dimensions of the adult. The power, therefore, by which
this reproduction is accomplished, would seem to be, not the mere revival
of one which, after perfecting the body, had lapsed into a dormant state,
but the self-same power which, before the removal of the limb, was
occupied in its maintenance by the continual mutation of its particles,
and is now engaged, with more energy, in the reconstruction of the
whole.
The ability to repair the damages sustained by injury, and to repro-
duce lost parts, appears to belong, in some measure, to all bodies that
have definite form and construction. It is not an exclusive property
of living beings ; for even crystals will repair themselves when, after
pieces have been broken from them, they are placed in the same condi-
tions in which they were first formed.
The diagram (Fig. 10) represents a series of casts made from a crys-
tal with which I imitated the experiments of Jordan.* A large piece
was broken off an octohedral crystal of alum (a). Before the fracture
it was perfect in its form, except at one small pit on its surface, where
• MUller'8 Arcfaiv, 1842, p. 46.
9
122 OBHEBAL C0NBIDERATI0N8 ON THE RBPAIK AKD
it had what (writing of animal physiology) might be called a congenital
defect. Thus broken (b) it was placed again in the solution in which
it had been formed, and after a few days its injury was so far repaired
as it appears in the figure (c). The whole crystal had increased, but
the increase on its broken surface was proportionally so much greater
than on any other, that the perfect octohedral form was nearly regained.
The little congenital defect, also, wbs completely healed. In a few
days more the whole crystal would have been as if it had suffered no
injury.
I know not what amount of mutual illustration, if any, the repair of
crystals and of living bodies may afford ; but, in any case, we may trace
here something lite a universal property of bodies that are naturally
and orderly constructed : all, in favorable circumstances, can repair at
least some of the damages to which they are liable from the violence of
external forces.
But, to speak only of the repair and reproduction that occur in the
several orders of the animal kingdom : among these they exist in sin-
gularly different degrees, and in such as can be only partially included
in rules or general expressions. The general statement sometimes
made, that the reparative power in each species bears an inverse ratio
to its position in the scale of animal life, is certainly not proved ; and
many instances are contrary to it: such as the great 'reparative power
possessed by the Triton and other lizards, and the apparently complete
absence of it in the perfect insects. Rather, the general rule which
we may expect to find true, and for which there is already much evi-
dence, may be that the reparative power bears an inverse proportion to
the amount of power consumed in the development and growth of the
individual, and in its maintenance in the perfect state.
Our ideas of the consumption of power in the organization of matter,
are, perhaps unavoidably, very vague : yet are there facts enough to
prove that the power which can be exercised in a germ is limited, so
that the capacity of assuming the specific organic form cannot be com-
municated to an indefinite quantity of matter ; and there are also enough
to justify the expression, that the power, thus limited, is in some mea-
sure consumed, 1st, in the development of every new structure, and,
REPRODUCTION OP INJURED AND LOST PARTS. 123
2dlj, in a less measure, in the growth and maintenance of those already
formed.
Thus, first, it appears constantly true, that the reparative power is
greater in all parts of the young than in those of the older individuals
of all species. Even when we compare individuals that have all at-
tained their highest development and growth, this rule seems to be
true. We know it from general observations of the results of similar
injuries and diseases in persons of different ages : numerous as the ex-
ceptions may be, the general rule seems true. And it is yet more evi-
dently proved in the case of some lower animals. Spallanzani men-
tions it in regard to the reproduction of the tail of the tadpole. The
quickness with which the work of reproduction is both begun and per-
fected was always, in his experiments, in an inverse ratio to the age.
He says the same for the reproduction of legs of salamanders ; and it
is only in the young, among frogs and toads, that any reproduction of
th^ limbs will take place. So, too, in experiments on the repair of
fractures, the unioa of tendons and the like, in the mammalia, one may
see abundant evidence that the vigor and celerity of the process are in
an inverse proportion to the animal's age. There is, indeed, some
reason to believe, that in the very early period of embryonic life, a
true reproduction of parts of limbs may take place even in the human
species. Not to speak of the possibility that supernumerary members
may be formed in consequence of accidental fission of the budding
limbs of the embryo, there are cases in which fingers are found on the
stumps of arms in such circumstances as justify the belief, that after a
limb had been accidentally amputated in the uterus, these had been
produced on its remaining portion.*
All these facts agree well with the belief that the formative power is
gradually diminished in the acts of organizing matter for the mainte-
nance of the body ; and the difference between the completeness of re-
pair in children and that in adults appears so much greater than the
difference in adults of different ages, that it is probable the formative
power is more diminished by growth than by mere maintenance.
But, secondly, it seems that the capacity for the repair or repro-
duction of injured parts is much more diminished by development, than
by growth or maintenance of the body ; t. e., much more by those trans-
formations of parts by which they become fitted for higher offices, than
by the multiplication or maintenance of those that are already perfect
in their kind and function. In other words, to improve a part requires
more, and more perfect, formative power, than to increase it does.
This, as a general principle, is exemplified in many instances. In
the greater part of congenital malformations we find arrest of develop-
ment, but no hindrance of growth ; as a heart, in which a septum fails
to be developed, yet grows to its full bulk. If tadpoles be excluded
* See a paper by Dr. Simpson, in the London and Edinburgh Monthly Journal, Jan., 184 S.
124 GENERAL CONSIDERATIONS ON THE REPAIR AND
from due light and heat, their development will be much retarded, but
their growth will be less checked : in other words, the cpnditions of nu-
trition which are enough for growth are not suflScient for development.
When a part is, without disease, unduly supplied with blood, it may
grow beyond its normal size, but it is never developed beyond its nor-
mal structure : that which is sufficient for increase of growth, is not
enough for an advance in development. Again, in the miscalled culti-
vation and improvement of flowers, growth is increased, but develop-
ment is hindered ; and an excess of colored leaves is formed, instead of
the due number of male and female organs. In an old ulcer or a sinus,
cells may be continually reproduced, maintaining or even increasing
the granulations, yet they will not develop themselves into connective
tissue and cuticle for the healing of the part. And so, lastly, even
when repair and reproduction have gone far towards their ultimate
achievement, that which takes a longer time, and oftener fails, is the
improvement, the perfecting of the new material, by its final develop-
ment. This is observed in all cases of reproduced limbs, and even in
ordinary scars.
These facts (and there are many others like them) seem to justify the
expression that, not only more favorable conditions, but also a larger
amount of organizing force, are expended in development than in growth,
or maintenance ; and that the reparative power bears an inverse ratio
to the amount of force already expended in these processes. If it be ^
so, we might expect that in each species, in its perfect state, the repara-
tive power might be measured by the degree of likeness between the em-
bryonic and the perfect form, structure, and composition.
There are many apparent exceptions to such a rule, especially in the
Asteridae, which, though constructed through manifold metamorphoses,
have great capacity of restoring detached rays;* yet it is consistent
with such a rule that the highest amount of reparative power exists in
those lowest polypes in which the materials of the germ-mass are least
transformed, but are multiplied, and, as it were, grouped into the shape
of their bodies. In the Hydra viridis, and Hydra fusca, it seems lite-
rally true that any minute portion derived from the germ-mass may,
after being separated from the perfect body, reproduce the perfect
form. This is the general truth of the numerous experiments performed
on Hydrae by Trembley, Roesel, and others. They have been so often
quoted, that I need not do more than mention the greatest instances of
reproductive power that they showed.
Trembley cut a Hydra into four pieces : each became a perfect Hy-
dra ; and, while they were growing he cut each of these four into two
or three. These fractions of the quarters being on their way to become
perfect, he again divided these, and thus he went on, till from the one
Hydra he obtained fifty. All these became perfect ; he kept many of
* A good account of the mode of reproduction of lost rays in the Asteridse may be found,
by Dr. H. S. Wilson, in the Trans. Linnsean Soc. 1860.
REPRODUCTION OF INJURED AND LOST PARTS. 125
them for more than two years, and they multiplied by their natural
gemmation just as much as others that had never been divided. Again,
he cut similar polypes longitudinally, and in an hour or less each half
had rolled itself, and seamed up its cut edges, so as to be a perfect
Hydra. He split them into four ; he quartered them ; he cut them
into as many pieces as he could; and nearly every piece became a
perfect Hydra. He slit one into seven pieces, leaving them all con-
nected by the tail, and the Hydra became seven-headed, and he saw all
the heads eating at the same time. He cut off the seven heads, and.
Hydra-like, they sprang forth again. And even the fabulist dared not
invent such a prodigy as the naturalist now saw. The heads of the
Lemsean Hydra perished after excision : the heads of this Hydra grew
for themselves bodies, and multiplied with as much vigor as their
parent-trunk.
Now these instances may suffice to show not only the great capacity
of reproduction in the lowest polypes, but, also, that in them the pro-
cess of reproduction after injury confounds itself with that of their
natural generation by gemmation, or, as it probably more rarely hap-
pens, by spontaneous fission. We cannot discern a distinction between
them ; and there are facts which seem to prove the identity of the
power which operates in both. Thus, in both alike, the formative
power is limited according to the specific characters of the Hydra ; im-
mense as the power of increase is which may be brought into action by
the mutilations of the Hydra, yet that power cannot be made to pro-
duce a Hydra of much more than ordinary size, or to raise one above
its ordinary specific characters. And, again, the identity of the power
is shown in this, that the natural act of gemmation retards that of re-
production after injury. Trembley particularly observes, that when a
Hydra, from which the head and tentacula had been cut off, gemmated,
the reproduction of the tentacula was retarded soon after the geramule
appeared.
Many other species manifest this coincidence of the power of propa-
gating by gemmation or fission, and of reproducing large portions of
the body, and even of reconstructing, from fragments, the whole body.
Among them, as chief examples, are the Actiniae, which, after bisection
form two individuals ; and the Holothurise, which, as Sir J. G. Dalyell
has observed, when hurt or handled, will eject all their viscera, leaving
their body a mere empty sac, and yet in three or four months will have
all their viscera regenerated. And to these may be added, from among
the Annelida, the young Nereids, and those species of Nais, on which
Bonnet, Spallanzani, and others, made their experiments ; experiments
of which the climax seemed to be achieved when a Nais was cut by
M. Lyonnet into thirty or forty separate pieces, and there were pro-
duced from those fragments as many perfect individuals.
Among the instances of greatest capacity of repair, some observed
126 QBHERAL CONSIDERATIONS ON THE BBPAIB AND
by Sir J. G. Dalyell* seem to illustrate, in a remarkable manner, the
general laws of the reparative processes in even the higher animals.
In Actinia lacerata, Dalyell observed that nnmeroua ragged processes
were put forth from the whole circumference of the disc, which were
gradually torn off, and became afterwards developed into minute
Actintee. Observations of a similar nature have been made by Dr.
Strcthill Wrigbtf with regard to Actinia dianthus. The latter author,
after noting the process of natural fissure in Actinia dianthus, pro-
duced similar phenomena by artificial fissure. From the foot of a
specimen of this Actinia, which showed no tendency to natural genera-
tion, he detached a very minute portion, which by careful examination
he satisfied himself contained no ovum or structure different from the
ordinary tissue of the wall of the body. This minute portion in three
weeks became a perfect Actinia. From this product of artificial fissure,
again, he divided other portions, which also in time developed into
perfect animals. All that appeared to he necessary to this process of
multiplication being the- existence in the severed part of the three
elemental tissues of the body, — the dermal, muscular and mucous.
In the Hydra tuba, the species in which Dalyell traced that mar-
rellous development into Medusfe, he found that when cut in halves,
Pig. 11.
each half may regain the perfect form ; hut this perfect form is regained
only very slowly, and, as it were, by a gradual improvement of parts
that are at first ill-formed. The sketch, copied from his plate, shows
the succession of forms marking these stages of improvement in the
distill part of a Hydra tuba (a), which had been detached by cutting
through the animal with a pair of scissors.
Through these forms, commencing at b, into which the distal or free
half of A was first changed, the perfect state of a Hydra was at length
reached; as at o. The obliteration of the old tentacles, together with
the changes which take place in the new before they assume their fully
developed form, may possibly be explained (as he suggests) by the mu-
* Rare and Remarkable Animals ofScoilanJ, vol. i, pi. 14; vol. ii, p. S30, pi. 47.
t Proc. Boy. Phy», Soc. Ed., vol. i. 161.
REPRODUCTION OP INJURED AND LOST PARTS. 127
Fig. 12.
A.
B.
C.
tilation having disturbed the progress of the Hydra in its development
of young Medusae ; for the experiment
was made in March, nearly at the time
when the series of changes should have
commenced. But, if I may venture
not to accept the suggestion of so ad-
mirable an observer, I should suspect
rather that this is an instance of gra-
dual recovery of perfection, such as we
see more generally in the repair of in-
juries and diseases in the higher ani-
mals.
He has noticed something of the
same kind, and more definite, in the
Tubularia indivisa (PI. iii) ; one of his
experiments on which is illustrated by
Fig. 12. A fine specimen was cut near
its root, and after the natural fall of its
head, the summit of its stem was cloven.
An imperfect head was first produced,
at right angles to the stem, from one
portion of the cleft (a) ; after its fall,
another and more nearly perfect one
was regenerated, and, as it grew, improved yet more (b). A third ap-
peared, and then a fourth, which was yet more nearly perfect, though
the stem was thick, and the tentacula imperfect. The cleft was almost
healed ; and now a fifth head was formed, quite perfect (c) ; and after
it, as perfectly, a sixth and a seventh head. All these were produced
in fifteen months.
The lower half of this specimen had been cut oflF four months after
the separation of the stem. Its upper end bore — first, an abortive
head ; then, secondly, one which advanced further in development ; a
third, much better ; and then, in succession, other four, which were all
well formed.
The upper portion of this lower half of the stem now showing signs of
decay, a portion was cut from its lowest part, and further manifested the
reproductive power of the stem ; for three heads were produced from the
upper end of the piece cut ofi*, and four from the lower end of the upper
piece which had seemed to be decaying. In 550 days this specimen
had grown twenty-two heads.
Now, I cannot but think that we have, in these instances of gradual
recovery from the effects of injury, a type of that gradual return to the
perfect form and composition which is noticed in the higher animals.
Our theory of the process of nutrition leads us to believe that, in the
constant mutation of particles in nutrition, those elements or those
molecules of the blood, or of any structure, that have been altered by
128 GENERAL CONSIDERATIONS ON THE REPAIR AND
disease, in due time degenerate or die, and are cast off or absorbed ; and
that those which next succeed to them partake, through the assimilatiye
force, of the same morbid character ; but that, every time of renewal,
the new particles approach a step nearer to the perfect state. Thus, as it
were, each generation of new particles is more nearly perfect, till all the
effects of injury or the disease are quite obliterated. Surely, in the
gradual recovery of perfection by these polypes, we have an apt illus-
tration of the theory ; one which almost proves its justice.
The power of reconstructing a whole and perfect body, by the de-
velopment of a fragment, is probably limited to the species that can
propagate by spontaneous fission or gemmation, or that increase their
size, as some of the Annelida do, by the successive addition of rings
that are developed after the manner of gemmules from those that pre-
cede them. Where this power is not possessed, there, whatever be the
position of the species in the animal scale, the reparative power appears
to be limited to the reproduction of lost members ; such as legs, claws,
a part of the body, the head, an eye, the tail, and the like. Within this
limit, the rule seems again to hold good, that the amount of reparative
power is in an inverse ratio to that of the development, or change of
structure and mode of life, through which the animal has passed in its
attainment of perfection, or on its way Ihitherward.
Here, however, even more than in the former cases, we need, not
perhaps more experiments, but experiments on a larger number of
species. It appears generally true, that the species whose development
to the perfect state is comparatively simple and direct, have great re-
parative powers ; while many, at least of those in which the develop-
ment is with such great changes of shape, structure, and mode of life,
as may be called metamorphosis, retain in their perfect state scarcely
any power for the repair of losses. Yet we want more instances of
this ; and especially, it were to be wished that we had the results of ex-
periments upon the lowest animals that pass through such metamor-
phoses ; e. g. on the Hydra tuba, not only in its Hydra state, but in all
the changes that succeed, till it attains its complete Medusal form.
In the absence of such evidence as experiments of this kind might
furnish, the best examples of the rule are furnished by the experiments
of Mr. Newport. They show that among the insects, the reparative
power, in the complete state, is limited to the orders in which that
state is attained by comparatively simple and direct course of develop-
ment ; as the Myriapoda and Phasmidje, and some of the Orthoptera.
These can reproduce their antennae, and their legs, after removal or mu-
tilation ; but their power of reproduction diminishes as their develop-
ment increases. Even in the Myriapoda, whose highest development
scarcely carries their external form beyond that of the larvae of the
more perfect insects, such reparative power apparently ceases, when,
BEPBODUCTION OF INJURED AND LOST PARTS. 129
after the last casting of their integuments, their development is com-
pleted.
In the higher hexapod insects, such reproduction has been seen in
only the larval state ; none of them, in its perfect state, can reproduce
an antenna, or any other member. The Myriapoda, then, are, in their
reparative power, equal to the larvae of the higher insects, and nearly
all the power for formation which these manifest, appears to be ex-
hausted in the two later metamorphoses.
The case is the stronger, as illustrating the expenditure of power in
metamorphses, when the higher insects are compared with the Arach-
nida ; for in these, which attain their perfect state through more direct
development, the reparative power remains equal to the reproduction of
limbs and attennsB. A yet stronger contrast is presented between the
higher insects and the several species of salamander, in which so pro-
fuse a reproduction of the limbs has been observed ; for though they be
much higher in the scale of animal life, yet the amount of change in
external form and habits of life, through which they pass, in their de-
velopment from the embryo to the perfect state, appears less than that
accomplished in the metamorphoses of insects.
Many instances, besides those which I have cited, appear to support
this rule, that the reparative power, in each perfect species, whether it
be higher or lower in the scale, is in an inverse proportion to the amount
of change through which it has passed in its development from the em-
bryonic to the perfect state. And the deduction we may make from
them is, that the powers for development from the embryo are identical
with those exercised for the restoration from injuries : in other words,
that the powers are the same by which perfection is first achieved, and
by which, when lost, it is recovered.*
This is, again, generally confirmed in the instances of the Vertebrata ;
but of the repair in these, or at least in the highest of them, I shall
have to speak so exclusively in the future lectures, that I will now only
say that, in man and other mammalia, a true reproduction after loss or
injury seems limited to three classes of parts :
1. To those which are formed entirely by nutritive repetition, such
as the blood and the epithelia.
2. To those which are of lowest organization, and (which seems of
more importance) of lowest chemical character ; as the gelatinous tis-
sues, the connective, and the bones.
3. To those which are inserted in other tissues, not as essential to
their structure, but as accessories, as connecting or incorporating them
with the other structures of vegetative or animal life ; such as nerve-
fibre and bloodvessels.
With these exceptions, injuries or losses in the human body are ca-
pable of no more than repair, in its most limited sense ; i. e. in the
* ObservatioDS on the mode of reproduction of lost parts in the Crustacea, by H. D. S.
Goodsir, may be found in the Anat. and Path. Observations, Edinburgh, 1845.
L.
130 GENERAL CONSIDERATIONS ON THE REPAIR AND
place of what is lost, some lowly organized tissue is formed, which fills
up the breach, and su£Sces for the maintenance of a less perfect life.
I may seem in this, as in some earlier lectures, to have been discuss-
ing doctrines that can hardly be applicable to our daily practice, and
with illustrations drawn from objects in which surgeons may have but
little interest. Let me, then, if only in apology, refer to some of the
considerations which are suggested by studies such as these. Let me,
first, express my belief that, if we are ever to escape from the obscuri-
ties and uncertainties of our art, it must be through the study of those
highest laws of our science, which are expressed in the simplest terms in
the lives of the lowest orders of creation. It was in the search after
the mysteries — that is, after the unknown highest laws— of generation,
that the first glance was gained of the largest truth in physiology, — ^the
truth of the development of ova through partition and multiplication of
the embryo-cells. So may the study of the repair of injuries sustained
by the lowest polypes lead us to the clearer knowledge of that law, in
reliance upon which alone we dare to practice our profession. — the law,
that lost perfection may be recovered by the operation of the powers by
which it was once achieved. Already, in the facts that I have quoted
from Sir J. Graham Daly ell, we seem to have the foreshadowing of those
through which the discovery may be made.
Then, let us not overlook those admirable provisions, which we may
find in the lives of all that breathe, against injuries that, but for these
provisions, would too often bring them to their end before their appointed
time, or leave them mutilated to finish a painful and imperfect life. We
are not likely to undervalue, or to lose sight of, the design of all such
provisions for our own welfare. But we may better appreciate these,
if we regard them as only of the same kind as those more abundantly
supplied to creatures whom we are apt to think insignificant : indeed,
so abundantly, that, as if with a consciousness of the facility of repair,
self-mutilation is commonly resorted to for the preservation of life.
When the Ophiuradae, or any of the brittle Star-fishes, break them-
selves to fragments, and disappoint the grasp of the anxious naturalist,
they probably only repeat what they are instinctively taught to do,
that they may elude the jaws of their more ravenous enemies. But
death would be much better than such mutilation, if their rays could
not be reproduced almost as easily as they can be rejected. The ex-
perimentalist, too, who cuts ofi* one or the other end of any of the An-
nelida, perhaps only puts them to a necessity to which they are liable
from the attacks of their carnivorous neighbors. Almost defenceless,
and so easily mutilated, their condition, were it not for their faculty of
reproduction, might be more deplorable than that of any other creature ;
and even their existence as species might have been endangered long
ago. It would almost seem as if the species that have least means of
escape or defence from mutilation were those on which the most ample
I
REPRODUCTION OF INJURED AND LOST PARTS. 131
power of repair has been bestowed ; an admirable instance, if it be only
generally true, of the beneficence that has provided for the welfare of
even the least (as we call them) of the living world, with as much care
as if they were the sole objects of the Divine regard.
Lastly, if I may venture on so high a theme, let me suggest that the
instances of recovery from disease and injury seem to be only examples
of a law yet larger than that within the terms of which they may be
comprised ; a law wider than the grasp of science ; the law that ex-
presses our Creator's will for the recovery of all lost perfection. To
this train of thought we are guided by. the remembrance that the healing
of the body was ever chosen as the fittest emblem of His work, whose
true mission was to raise man's fallen spirit and repair the injuries it
had sustained ; and that once, the healing power was exerted in a man-
ner purposely so confined as to advance, like that which we can trace,
by progressive stages to the complete cure. For there was one, upon
whom, when the light of Heaven first fell, so imperfect was his vision,
that he saw confusedly, " men as trees walking ;" and then by a
second touch of the Divine Hand, was " restored, and saw every man
clearly." Thus guided by the brighter light of revelation, it may be
our privilege, while we study the science of our healing art, to gain by
the illustrations of analogy, a clearer insight into the Oneness of the
plan by which things spiritual and corporeal are directed. Even now,
we may trace some analogy between the acts of the body and those of
man's intellectual and moral nature. As in th6 development of the
germ, so in the history of the human spirit, we may discern a striving
after perfection ; after a perfection, not viewed in any present model
(for the human model was marred almost as soon as it was formed), but
manifested to the enlightened Reason in the " Express Image" of the
*' Father of Spirits." And so, whenever, through human frailty, amid
the violences of the world, and the remaining " infection of our nature,"
the Spirit loses aught of the perfection to which it was once admitted,
still its implanted Power Ig ever urgent to repair the loss. The same
power, derived and still renewed from the same Parent, working by the
same appointed means, and to the same end, restores the fallen spirit
to nearly the same perfection that it had before. Then, not unscarred,
yet living — " fractus sed invictus" — the Spirit still feels its capacity
for a higher life, and presses to its immortal destiny. In that destiny the
analogy ends. We may watch the body developing into all its marvel-
lous perfection and exact fitness for the purpose of its existence in the
world ; but, this purpose accomplished, it passes its meridian, and then
we trace it through the gradual decays of life and death. But, for the
human Spirit, that has passed the ordeal of this world, there is no such
end. Emerging from its imprisonment in the body, it soars to the ele-
ment of its higher life : there, in perpetual youth, its powers expand, as
the vision of the Infinite unfolds before it ; there, in the very presence
of its Model, its Parent, and the Spring of all its power, it is '' like Him,
for it sees him as He is."
132 REPARATIVE MATERIALS.
LECTURE VIII.
THE MATERIALS FOR THE REPAIR OF INJURIES.
In the present lecture I propose to give a general account of the
materials employed for the repair of some of the injuries inflicted on
the human body.
I hope I do not err in thinking that the most advantageous mode of
treating this subject will be to confine myself to that class of injuries
which may be called visible breaches of continuity ; such as wounds
and fractures. For, in regard to the recovery from diseases, our
knowledge of the effects of any disease seems, as yet, too imperfect for
us to trace the stages by which the morbid state reverts to that which
is healthy. We may be sure it is in conformity with the same general
laws as those of recovery from injury, and almost sure that it is by
the gradual improvement of the particles that in succession replace
those altered by disease. But the whole details of the process have
yet to be discovered.
Even within the narrower field of the repair of breaches of con-
tinuity, I must yet assign to myself a closer limit. A future lecture
will be devoted to the healing of fractures ; in this, therefore, I shall
speak almost exclusively of the healing of divided soft parts ; and I
shall take, as the chief and typical examples, the repairs of wounds
made in operations. References to the healing of other injuries may,
however, be made by the way, and for collateral illustration.
Modern surgery has shown how right Mr. Hunter was, when, in the
very beginning of his discussion concerning the healing of injuries, he
points out, as a fundamental principle, the difference between those
two forms of injuries of which one is subcutaneous, the other open to
the air. He says : '^ The injuries done to sound parts I shall divide
into two sorts, according to the effects of the accident. The first kind
consists of those in which the injured parts do not communicate ex-
ternally, as concussions of the whole body, or of particular parts,
strains, bruises, and simple fractures, which form a large division. The
second consists of those which have an external communication, com-
prehending wounds of all kinds and compound fractures.*** And then,
he says, " The injuries of the first division, in which the parts do not
communicate externally, seldom inflame ; while those of the second
commonly both inflame and suppurate.*'
In these sentences Mr. Hunter has embodied the principle on which
is founded the whole practice of subcutaneous surgery ; a principle of
which, indeed, it seems hardly possible to exaggerate the importance.
* Works, vol. iii, p. 240.
REPARATIVE MATERIALS. 133
For, of the two injuries inflicted in a wound, the mechanical distur-
bance of the parts, and the exposure to the air of those that were
covered, the exposure, if continued, is the worse. Both are apt to ex-
cite inflammation ; but the exposure excites it most certainly, and in
the worse form ; t. «., in the form which most delays the process of
repair, and which is most apt to endanger life. Abundant instances
of this are shown in the difi*erence between a simple and a compound
fracture, though the former may have been produced by the greater
violence ; or, between a simple fracture, even with much violence, ex-
tending into a joint, and an open wound, never so gently made into
one. Or, for parallel instances, one may cite the rarity of suppurations
after even extensive ecchymoses, and their general occurrence when
wounds are left open.
I had frequent occasion to observe these differences, in a series of
experiments made for the illustration of the healing of divided muscles
and tendons. Some of these were divided through open wounds, and
some by subcutaneous section ; and the recital of a single experiment
may afford a fair example of the difference of results that often ensued.
In the same rabbit, the tibialis anticus and extensor longus digitorum
were divided on the right side with a section through the skin ; on the
left, with a subcutaneous section, through a small opening. Twelve
days afterwards the rabbit was killed. The wound on the left side was
well repaired, and with comparatively little trace of inflammation : the
gap on the right was closed in with a scab, and an imperfect scar, but
under these was a large collection of pus, and no trace of a reparative
process. The contrast is the stronger, because in all these cases there
is, unavoidably, more mechanical violence inflicted in the gradual sub-
cutaneous division than in the simple open wound. And, it must be
added, that a speedy closure of the external wound made in an open
section may bring the case into more favorable conditions than those
of a subcutaneous wound made with more violence. This, also, I saw
in some of the experiments: a clumsy subcutaneous division of one
Achilles-tendon excited great inflammation about it ; while the open
section of the other tendon in the same rabbit was quickly and well
repaired, if the external wound had been speedily united, and had suffi-
ciently soon converted the open into a subcutaneous injury.
Still, what Mr. Hunter said is true, especially in wounds in our own
bodies : subcutaneous wounds seldom inflame ; open wounds generally
both inflame and suppurate. It will be a principal object of this lec-
ture to show something like an anatomical reason for this difference, in
the fact that the materials produced for the repair of open wounds are
not usually the same, or, at least, do not develop themselves in the
same manner, as tho^e for the repair of closed or subcutaneous ones.
The physiological and nearer reason is probably to be discovered in the
influence of oxygen abnormally admitted to the tissues, and producing
134 REPARATIVE MATERIALS.
in them such effects as are more nearly traced in the phenomena of
inflammation, and will be described in future lectures.
Before speaking of the materials for repair, I must briefly state that
the healing of open wounds may be accomplished by five different
modes : namely, 1. By immediate union ; 2. By primary adhesiop ;
3. By granulation ; 4. By secondary adhesion, or the union of granu-
lations ; 5. By healing under a scab. The repair of subcutaneous
w^ounds may be effected by immediate union, but is generally accom-
plished by connection, or the formation of bonds of union between the
divided and retracted parts. Very rarely it is effected by means of
granulations without suppuration.
Of these modes, which I hope to describe hereafter in detail, it is
the peculiarity of the first, or process of immediate union, that it is
accomplished by the mere reunion or rejoining of the divided parts,
without the production or interposition of any new material. In all
the others, new material is produced and organized. This process of
immediate union corresponds with what Mr. Hunter called " union by
the first intention.** It is not the same as that which, in modern sur-
gery, is called union by the first intention ; for that is the same as
Mr. Hunter named "union by adhesion,** or "by the adhesive inflam-
mation,** and is effected, as he described it, by the organization of
lymph interposed between two closely approximated wounded surfaces.
Mr. Hunter maintained that union by the first intention is effected by
means of the fibrine of the blood extravasated between the surfaces of
the injured part, which fibrine, there coagulating, adheres to both the
surfaces, becomes organized, and forms a vascular bond of union be-
tween them.* Doubtless, Mr. Hunter was, in this, in error; but, as
the blood extravasated in wounds is not without infiuence on their
repair, I will endeavor to state the several modes in which it may, when
thus extravasated, be finally disposed of.
There are ample evidences for believing that masses of effused, or
stagnant and coagulated, blood may be organized ; i. e, may assume the
characters of a tissue, and may coalesce with the adjacent parts and
become vascular. These evidences include cases of blood effused in
serous sacs, especially in the arachnoid ; of clots in veins organizing
into fibrous cords, or, after less organization, degenerating into phle-
bolithes ; clots organizing into tumors in the heart and arteries, and
the clots so organized above ligatures on arteries as to form part of
the fibrous cord by which the obliterated artery is replaced. These
last cases afford most conclusive evidence, because they have been very
carefully investigated in a series of experiments and microscopic obser-
vations, by Dr. Zwicky.|
In 1848, I had the opportunity of examining a specimen which, more
♦ Works, vol. iii, 253. f Die Metamorphose des Thrombus. Zurich, lb45.
BEPABATITE HATSRIALS.
135
fully than any other I bad Been, confirmed Zwicky's account of the
mode in which blood-clots become organized. It supplied, too, some
facts which appear important to the present subject. It was obtained
from an insane person, by my friend Mr. Holmes Coote. A thin layer
of pale blood-colored and ruddy membrane lined the whole internal
sntface of the cerebral dura mater, and adhered closely to it. Its
color, the existence of patches of blood-clot imbedded in it, and all its
other characters, satisfactorily proved that it had been a thin clot of
blood,— an example of such as are effused in apoplexy of the cerebral
membranes, and are fully described by Mr. Frescott Hewett.* Mu-
merODS small vessels could be seen passing from the dura mater into
this clot-membrane ; and with the niicroBcope, while they were still full
of blood, I made the sketch engraved (Fig. IS, a). The arrangement of
the bloodvessels bears a close resemblance, but, perhaps, more in its
irregularity than in any positive characters or plan, io that which
exists in false membrane formed of organized lymph ; but the vessels
were, I think, generally larger.
Such were the bloodvessels of this organized clot. Its minute struc-
ture, as represented below (b), showed characters which are of peculiar
Fig. 18.
interest, because of their resemblance to those observed in the material
that is commonly formed in the repair of subcutaneous injuries. In
the substance of what else appeared like a filamentous clot of fibrine,
sprinkled over with minute molecules, the addition of acetic acid brought
into view corpuscles like nuclei, or cytoblasts, very elongated, attenu-
ated, and, in some instances, like short B^^ips of flat fibre. Of course,
such corpuscles are not to be found in any ordinary clot of fibrine ; they
* Med. Chit. Trana. vol. xzviii.
136 REPARATIVE MATERIALS.
exactly resemble such as may be found in certain examples of rudimen-
tal connective tissue, and among these, in the material for the repair of
subcutaneous injuries. In short, the minute structure of this clot liow
organized was an example of what I shall have often to refer to under
the name of " nucleated blastema.***
With such evidence as this of the organization of a thin layer of
blood-clot, and of the development of its fibrine being apparently iden-
tical with that of the material commonly formed for the repair of sub-
cutaneous injuries, I was surprised to find that extravasated blood can,
commonly, have no share at all in the reparative process.
One of the best proofs of this is, that scarcely the smallest portion
of blood is effused in the cases in which the largest quantity of repara-
tive material is produced in the shortest time, and in which the healing
process is most perfectly accomplished. In twenty cases in which I
divided the Achilles-tendon in rabbits, I only once found, in the subse-
quent examinations, a clot of extravasated blood in the track of the
wound. In this case, I believe, the posterior tibial artery was wounded:
for in all others, and in similar divisions of muscles, unless a large arte-
rial trunk were cut, the only effusion of blood was in little blotches, not
in separate clots, but infused or infiltrated in the areolar tissue near the
wound. In some cases there was blood-stained infiltration of the in-
flammatory products, but in none were there such clots as could be or-
ganized into bonds of union. In short, parts thus divided scarcely
bleed : what blood does flow escapes easily through the outer wound, as
the surrounding tissues collapse into the space left by the retracting
parts ; or, what remains is infiltrated into the tissues, and forms no
separate clot.
It is the same with fractures. In a large proportion of these, one
finds no clots lying between the fragments where they are to be united,
and only very small spottings of blood, like ecchymoses, in or beneath
the periosteum. The abundant extravasations that commonly exist in
the subcutaneous tissue are generally confined to it : they are not con-
tinued down to the periosteum or bone.
In all these cases, then, we have sufiicient proof that extravasated
blood is not necessary for union by the first intention, or for any other
mode of repair, in the simple fact that where the repair is best, and the
material for it most ample, no blood is so extravasated as to form a clot
that could be organized.
But, though this may be the usual case, the question still remains —
When blood is effused and coagulated between wounded surfaces, how
* The description here given has been fully confirmed by the examination of a similar
membranous clot, the vessels of which were beautifully injected by Mr. Gray (Pathol.
Trans.) ; and more recently by that of one injected by Mr. Coote. Dr. W. T. Gairdner, in
Edin. Med. Jour. Oct., 1851, also describes a specimen of false membrane from the arach-
noid cavity, in which bloodvessels containing blood-corpuscles were seen, and Dr. J. Ogle,
in Beale^s Archives^ vol. i, and part 6, records similar cases.
BLOOD. 137
are the clots disposed of ? For, often, though not generally, such clots
are found in wounds, or between the ends of a broken bone, or a di-
vided tendon when an artery by its side is cut ; and in most operation-
wounds, one sees blood left on them, or flowing on their surfaces, after
they are done up. How, then, is this blood disposed of?
If effused in large quantity, so as to form a voluminous clot, and
especially if so effused in a wound which is not perfectly excluded from
the air, or if effused in even a subcutaneous injury in a person whose
health is not good, the blood is most likely to excite inflammation ; and
the swelling of the woun(Jed parts, or their commencing suppuration,
will push it out of the wound. Thus we often see blood ejected.
But, in more favorable circumstances, the blood may be absorbed ;
and this may happen whether it have formed separate clots, or, more
readily, when it is infiltrated in the tissues. What I have seen, how-
ever, in the experiments to which I have already referred, leads me to
dissent from the account commonly given of the absorption of blood
thus effused. The expressions generally used imply that the first thing
towards the repair of such a wound is the absorption of the extrava-
sated blood ; and that then, in its place, the lymph or reparative mate-
rial is produced. But this can hardly be the case ; for the absorption
of blood is a very slow process, and commonly requires as much time
as would suffice for the complete healing of a wound, or even of a frac-
ture. Not to mention the very slow absorption of the extravasations
of blood in apoplexy or in serous sacs, I have found the blood effused
in the subcutaneous tissue and the muscles, after a simple fracture,
scarcely changed at the end of five weeks ; that in a tied artery was as
little changed after seven weeks : and even in common leech-bites we
may sometimes find the blood-corpuscles, in little ecchymoses, un-
changed a month after their extravasation : yet iti much less time than
this it is commonly implied that all the blood extravasated in an injury
is cleared quite away, that lymph may occupy its place. My impres-
sion is, that this opinion is founded on 'imperfect observations. Blood
is supposed to be effused in all subcutaneous injuries ; and where it is
not found, it is supposed to have been absorbed ; the truth rather being,
that, where no blood appears, none ever was.
The true method of the absorption of blood left in a wound seems to
be, that it is inclosed within the reparative material, and absorbed by the
vessels of that material as its organization proceeds. The best instance
that I have seen in support of this statement was in the case of a rab-
bit's Achilles-tendon, divided subcutaneously six days before death.
The reparative process had proceeded favorably, and as strong a band
of union as is usual at that period was formed of the new reparative
material deposited between the retracted ends. On slitting open this
band, I found within it a clot of blood, such as must have come from a
• large vessel ; and this clot was completely inclosed within the new ma^
terial ; not closely adherent to it, nor changed as if towards organiza-
10
138 REPARATIVE MATERIALS:
tion ; but rather, decolorized, mottled, and so altered as clots are in
apoplexy before absorption.
I believe that this case only showed in a very marked manner what
usually happens with blood thus effused and not ejected : for it is quite
common, after the division of tendons, to find new reparative material,
if not containing distinct clots, yet blotched with the blood that was
infiltrated in the tissue in which the reparative material is deposited :
and even when the repair of a fracture was nearly perfect, I have still
found traces of blood-corpuscles inclosed in the reparative material,
and degenerating, as if in preparation for absorption.
Ejection and absorption are, doubtless, the usual means by which
blood effused in injuries is disposed of; yet I feel nearly sure it may
in some instances become organized, and form part of the reparative
material. The cases of manifest organization of blood already referred
to leave no doubt of the possibility of this happening : its occurrence
can no longer be set aside as a thing quite improbable. The only
question is, whether blood effused in injuries has been seen organized.
Now I think no one familiar with Hunter's works will lightly esteem
any statement of his as to a matter of observation. He may have been
sometimes deceived in thinking that he saw blood becoming organized
in subcutaneous injuries (for subcutaneous granulations are sometimes
very like partially decolorized clots) ; yet I believe he was often right :
for sometimes one finds clots of blood about the fractured ends of bones
which have every appearance of being in process of organization.
They do not look mottled, or rusty, or brownish, as extravasated blood
does when it is degenerating, preparatory to its absorption ; but they
are uniformly decolorized to a pinkish-yellow hue. They have more
appearance of filamentous structure than recent clots have ; and they
are not grumous or friable, like old and degenerating ones, but have a
peculiar toughness, compactness, and elasticity, like firm gelatine.
When clots are found in this condition, I believe it is a sign that they
were organizing; for this is the condition into which, commonly, the
clot in a tied artery passes in its way to be fully organized; and
(which is very characteristic) you may find clots in the track of
wounded parts thus changing, as if towards organization, while those
about them, and out of the way of the reparative process, are degene-
rating.
On the whole, then, I believe we may thus generally conclude con-
cerning the part that blood, when it is extravasated, takes in the repair
of injuries:
1. It is neither necessary nor advantageous to any mode of healing.
2. A large clot, at all exposed to the air, irritates and is ejected.
3. In more favorable conditions the effused blood becomes inclosed
in the accumulating reparative material ; and while this is organizing,
the blood is absorbed ; and.
Lastly, it is probable that the blood may be organized and form part
i
LYMPH. 189
of the reparative material ; but even in this case it probably retards
the healing of the injury.
I proceed now to the consideration of the new material which is pro-
duced for the repair of injuries that are not healed by the immediate
union. It is that to which the general name of lymph, or coagulable
lymph, is given.
Our notions concerning the properties of this substance, when once
formed for the repair of injuries, are derived almost entirely from ex-
aminations of the lymph formed in acute inflammations, with which it
is supposed to be identical. The identity is far from being proved, but
their similarity is in many particulars evident, and especially in that
both mimifest, by their spontaneous coagulation, that they contain
fibrine. The coagulum which is spontaneously formed in reparative
material is, in microscopic characters, like that of fibrine: chemically,
too, they appear alike : and the organization of the fibrine of the blood
in the complete clot, as well as all the other circumstances which lead
to the opinion that fibrine is the principal material for organization into
tissues, justifies the belief that the lymph exuded for the purposes of
repair has fibrine for its principal constituent. However, when we
speak of fibrine as the chief reparative material, we must not have in
mind the pure organic compound that minute chemistry might obtain,
but rather that which exists in the natural, and seemingly rough, state,
— ^as fibrine, with some fatty matter, and some incidental saline con-
stituents ; for all these are found in all the specimens of coagulable
lymph that have been examined ; and without doubt they are essential,
as the so-called " incidental principles" always are, to the due construc-
tion of the substance to be organized.
Regarding its vital properties, the essential character of the coagula-
ble lymph is its tendency to develop itself; a tendency which it has of
its own properties. It thus displays itse]f as a plasma or blastema ; a
fluid to be classed with those others that manifest the capacity to assume
organic structure ; such as the lymph and chyle that develop them-
selves to blood, and the semen, which, at first fluid, gradually develops
itself into more and more complex structures.
The natural tendency of coagulable lymph is to develop itself into the
fibrous, or common fibro-cellular or connective, tissue — the lowest form
of vascular tissue, and the structure which, in nearly all cases in man,
constitutes the bond, by which disunited parts are again joined. This
is commonly formed, whatever be the tissue upon which the lymph is
placed, whether containing connective tissue in its natural structure or
not. This, therefore, we may regard as the common or general ten-
dency of lymph; but in certain cases the development of lymph passes
beyond this form, or deviates from it into another direction, in adapta-
tion to the special necessity of the part to be repaired. Thus, for the
repair of bone, the lymph may proceed a certain distance towards the
140 REPARATIVE MATERIALS:
t
development of fibrous tissue, as if for a common healing ; but this
fibrous tissue may next ossify ; or, not forming fibrous tissue at all, the
lymph may proceed at once to the formation of a nearly perfect carti-
lage, and this may ossify. In general, moreover, the character of t\^e
connective tissue that is formed in repair is adapted to that of the parts
that it unites. The bond for the union of a tendon is much tougher
than a common scar in the skin ; the scar in skin is tougher and less
pliant than that in mucous membrane, and so on.
But, passing by, for the present, the instances of special development
of the reparative material, in adaptation to special purposes or injuries,
let me speak of its development into fibrous, fibro-cellular, or connec-
tive tissue. I have said that, in its first production, the reparative ma-
terial is like the lymph of inflamed serous membranes ; at least, no
characteristic difference is yet known between these, which we might
call respectively, inflammatory and reparative lymph. Neither are
there yet any observations to show a difference in the primary charac-
ters of the materials effused for the repair of injuries of different parts,
or in different circumstances ; and yet such a difference, in even the
original properties of the reparative lymph, is indicated by the fact,
that, in different circumstances, it may proceed to the same end — ^the
formation of fibrous tissue — by two different ways of development.
The lymph, or new material, which is produced for the repair of open
wounds, generally develops itself into connective tissue through nu-
cleated cells ; that formed for the healing of subcutaneous wounds as
generally develops itself into the same tissue through the medium of
nucleated blastema.
Now, both these are repetitions of natural modes of development of
the same forms of tissue. And it must not appear an objection that
there should be two modes of development to the same perfect structure ;
for this is usual, and has been observed in nearly all the tissues. In the
development of the blood-corpuscles, a first set are formed from part of
the embryo-cells that form the germinal area, or the whole body of the
embryo ; and a second set are formed from the corpuscles of lymph and
chyle. So it is with the cartilage, the muscular, and other tissues that
are formed in the earliest periods of embryo-life. At first they are de-
veloped from some of the embryo-cells ; yet in later life no such cells
are seen among them,T)ut others appropriate to them, and of different
form. So also in the bones, which at first are developed through carti-
lage, but in their subsequent growth are increased by ossification of
fibrous tissue ; and in the repair of which we shall find even more numer-
ous modifications of these different developments.
The development of the fibro-cellular or connective tissue through
nucleated cells may be observed in the material of granulations, or in
that of inflammatory adhesions (whether in a serous sac or in a wound
healing by primary adhesion), in inflammatory indurations, and in the
LYMPH. 141
naturally developed connective tissue of many parts. The process is.
with slight and apparently not essential modifications, the same in all ;
and is, I believe, almost exactly described by Schwann.
Fig. U.»
The cells first formed in granulations are spherical, palely or darkly
nebulous, from about l-1800th to l-2500th of an inch in diameter. They
contain a few shining, dark-bordered granules, and lie imbedded in a
variable quantity of clear pellucid substance, by which they are held
together, and which it is hard to see, unless acetic acid be added. When
water is added, it penetrates the cells, and as they swell up their walls
appear more disttuct, and their contents are diffused. Some cells thus
become much larger and clearer, and show in their interior numer-
ous vibrating molecules : others display fewer molecules, hut a distinct
round, dark-bordered nucleus, which appears attached to thi! inside of
the cell-wall. Such a nucleus is rarely seen in granulation- cells, unless
they are distended with water: acetic acid, acting more quickly than
water, brings the nucleus more evidently and constantly into view, and
often makes it appear divided into two or three portions. f
In the development of fibro-cellular or connective tissue from these
cells, whether in the natural structures or in those that are formed in
disease or after injury, the first apparent change is in the nucleus.
It becomes more distinct ; then oval (even before the cell does), and at
the same time clearer, brighter, like a vesicle tenaelyfilled with pellucid
substance. One or two nucleoli now appeur distinctly in it, and soon
it attenuates itself; hut this it does later, or in a less degree, than the
eell ; for a common appearance is that of elongated cells bellied out at
the middle by the nucleus.
lie; lb.
e elongated cells in the
group lie low are skelcl
t The gtanulation-cell* are very .
like ih.
■ whit.
i or lymph-corpu
iscle:
s of the blood: bul
likene*. iniplicB nothing more thai
n llie general
1 fact thai mnny
itru
dure* which, in il
perfect stale, are widely different in
. form
as we
11 aB in office, b
which
ihfTB
are many oilier
insl
ances, seems the in
«,1y r
nentjoiie.!,— thai
the
aaine perfect olnici
mi]r have mrae iban one original o
r rudii
form, and mor.
! tha
n one melhoti of de
142 REPARATIVE MATERIALS:
While these changes are ensuing in the nucleus, each cell also is de-
veloping its structure; first becoming minutely, jet more distinctly,
granular and dotted; then having its cell-wall thinned, or even losing
it. It elongates at one or both ends, and thus are produced a variety
of lanceolate, caudate, or spindle-shaped cells, which gradually elongate
and attenuate themselves towards the filamentous form. As they thus
change, they also group themselves ; so that, commonly, one may find
the swollen part of each, at which the nucleus lies, engaged between the
thinner parts of the two or more adjacent to it. Thus, the filaments
into which the cells are developed are clustered or fasciculated : each
cell forming, I think, usually only one filament, and long filaments being
sometimes formed by the attachment of the ends of two or more, each
developed from a single cell.
In some granulations, but, I think, only in such as are formed on
bones, one may often find large compound cells, or masses, or laminse,
of blastema, of oval form, and as much as l-250th of an inch in diame-
ter, containing eight, ten, or more nuclei. They are like certain natu-
ral constituents of the medulla of bone (as described by KoUiker* and
Robin|); and like the bodies which are found constituting the chief part
of fibro-plastic tumors. Sometimes, also, even in the deeper parts of
granulations, cells are found expanded, flattened, scale-like, and nu-
cleated, as if approximating to the formation of epidermal cells.
Such, briefly, is the process for the development of fibro-cellular tis- '
sue through nucleated cells as observed in granulations. Some modifi-
cations of it may be noticed in certain cases, especially in regard to the
proportion that the cells bear to the substance in which they lie. In
some forms of granulations, as in some natural parts of the embryo, this
substance is abundant : and I presume that by its development or fibril-
lation it takes part in the formation of filaments. But none of the
modifications affect the essential characters of the process.
The development of the fibro-cellular or fibrous tissue through nu- •
cleated blastema is, as I have already said, best observed, among the
processes of repair, in the organization of the material by which, in
most cases, the bonds of connection after subcutaneous wounds are
formed. It is the same process which HenleJ regards as the only mode
of development of the fibro-cellular and fibrous tissues.
Of the union of divided tendons I hope to speak more fully in a future
lecture. For the present purpose, and in illustration of the develop-
ment of fibro-cellular or fibrous tissue from nucleated blastema, it may
be enough to state that, when the first exudation of the products of the
inflammation, excited by the violence of the wound, is completed, a
quantity of finely molecular or dimly-shaded substance, like homogene-
* Mikrosk. Anatomic, Figs. 113 and 121.
t Bull, de la Societe de Biologie, 1 849, p. l^O.
f Allgemeine Anatoinie. A similar process is described by Reichert, Zwicky and Geritch.
LYMPH. 143
ous or dotted fibrine, begins to appear in the apace in whicb the bond
ofuoioQis to be formed. This subetance is infiltrated in the tissue that
collapses into the space between the retracted ends of the tendon. At
first there is no appearance of nuclei or cytoblasts in it : it seems to be
merely a blastema of fibrine : but, as it acquires
firmness and distinctness, the nuclei appear in it. ^'K- 1^-
They presently appear as oval bodies, with dark
hard outlines, soon becoming elongated ; they have
clear contents, without nucleoli ; they are irregu-
larly scattered, but so firmly imbedded in the blas-
tema that, in general, they cannot be dislodged. They
may be seen in very fine fragments without re-
agents ; bat, commonly, the application of acetic
acid is necessary to make them distinct, by making
the intermediate substance transparent, while the
nuclei themselves appear to acquire darker edges
ind shrivel a little. The nuclei undergo compara-
tively little change, while the blastema in which they are imbedded is
acquiring, more and more distinctly, the filamentous appearance, and
then the filamentous structure. Only they appear to elongate, and to
attennate themselves, and to grow more irregular in their outlines, as if
by shrivelling, or by slight branching.
The blastema may become at length perfect connective tissue ; a tis-
sue not to be distinguished from that found in normal conditions. I
have Dot been able to find, as Henle describes, that the nuclei are de-
Teloped into fibres.
I have been thus minute in the account of these two modes of develop-
ment of connective tissue, prevailing alike in the natural structures and
in the materials of repair, because the knowledge of them may enable
ng to settle some questions respecting all the modes of healing, and be-
cause it seems to point out the essential anatomical difference in the
tealing of open and of subcutaneous wounds, with disconnection of
divided parts.
The general truth appears to be (as already stated) that the material
of repair for subcutaneous wounds of soft parts is developed through
the formation of nucleated blastema ; whilst that for repair by primary
tdhesion, and by granulation, is developed through nucleated cells.
JTow, since both these methods of development are, as I have already
said, imitations of natural methods, we might suppose that they are,
therefore, both alike natnral or healthy processes ; alike sure to pass to
their purposed end, safe from disease or degeneration. But, if we con-
rider also the morbid conditions in which these two methods of develop-
ment occur, we may find that the development through cells is charac-
teristic of a less perfect process of healing than that accomplished with
the nacleated blaatema that appears to originate in a fibrinous exuda-
144 REPARATIVE MATERIALS: LYMPH.
tion. For, in describing the products of inflammation, I shall have to
show, that in general, the inflammatory exudations which occur in ple-
thoric, sthenic conditions of the system, or in local disease in persons
otherwise sound, have the aspect of fibrinous substance, like the mate-
rials which are produced in subcutaneous injuries, and are developed
through nucleated blastema ; while, on the other hand, the inflammatory
exudations in debilitated persons, and in asthenic blood-diseases, assume
a corpuscular structure, like that of granulations upon open wounds.
Let me, however, in conclusion, state that, although I have described
the two modes of development of fibro-cellular or fibrous tissue for the
healing of wounds as if they were always as separate as they are
distinct, yet they may coexist, and probably often do so. In the
repair of many wounds, the two materials, namely, that which is to
be developed through nucleated cells, and that whose progress is to be
through nucleated blastema, may be mixed. Thus, in subcutaneous
wounds and injuries, the first consequence of the mechanical violence
is the exudation of a common inflammatory product, which makes the
areolar tissue oedematous, and usually organizes itself into nucleated
cells. Thus you find the space between the retracted parts of divided
tendons for about two days. But then, the more proper and purer ma-
terial of repair is produced ; and this, increasing in an inverse propor-
tion to the degree of inflammation, soon overwhelms the former product
of inflammation, and is developed into the nucleated blastema. Still,
for many days, traces of the inflammatory product may be discerned
mingled with the blastema, confusing its appearance, but, I believe,
finally organizing with it into the bond of union. So, in divided mus-
cles, and in simple fractures, the inflammatory exudation, produced in
consequence of the first violence, appears to mingle and develop itself
with the more proper material of repair ; but they bear an inverse pro-
portion to one another, and the more manifest the signs of the inflam-
mation, the less is the quantity of the proper reparative material, and
the slower, in the end, the process of repair.
On the other hand, I think that in the ordinary healing of open
wounds, which are soon brought together by sutures, or other appro-
priate means, there may be less than the commonly observed formation
of nucleated cells, and some of the reparative material may be developed
through the nucleated blastema. Or, when the different materials are
not mingled at the same spot, yet, in a single wound, different parts
may be healed by the organization of one or other material, according
to the degree of inflammation that is in each part present.*
* The structure and mode of development of the fibro-cellular, fibrous, or coDnective tis-
sue, has, during the last ten years, more especially in Germany, formed the special subject
of investigation of physiologists and pathologists, and many observers have adopted opi-
nions on these questions, which differ greatly from those originally announced by Schwann,
and incorporated in the text. As the whole subject must still be considered to be in an un-
settled state, it has been thought advisable to leave the text very much as it was in the for-
HEALING BY IMMEDIATE UNION. 145
LECTURE IX.
THE PROCESSES OF REPAIR OF WOUNDS.
1 PROCEED now to the description of the several modes of healing of
wounds, and shall at present speak of only such wounds as are exter-
nally open. Among the modes which I enumerated, the first was that
which, as I stated in the preceding lecture, is effected by immediate
nnion. It corresponds with what Mr. Hunter called union by the first
mer edition, and to throw the new views in the form of a note. It is to Virchow and Bon-
ders that we are especially indebted for the observations on which these new views have
been founded. At first much opposition was advanced to their statements. Kolliker, even
is the last edition of his ** Manual of Microscopic Anatomy/' still held by the old description of
Schwann, but in a recent elaborate paper (Neue Untersuchungen Uber die Entwicklung des
Biodege webes ; Wiirzburg, 1861), he has, to a great extent, announced his adhesion to the
doctrines of Virchow and Bonders. These observers argue that the fibril lated bundles are
not formed from cells, but that they arise in the substance lying between and separating
the cells from each other, that they are therefore peculiar modifications of intercellular sub-
stance. They consider that the cells themselves remain in the texture and constitute the
C0Dne<^tive-tis8ue corpuscles. Although capable of undergoing con.siderable modifications,
both of shape and chemical composition, yet they frequently become elongated and send
oat processes, partly from their ends and partly from their sides, which extend between
adjacent bundles of fibrillar, so that the processes proceeding from one cell become con-
nected to those belonging to adjacent cells. In this manner a stellated, or radiated anasto-
roomng system of cells is formed, between which the bundles of fibrillae are situated. This
system of cells in its relation to the mode of nutrition of the connective tissue, has been
already referred to on p. 48. Anatomists had long been familiar with the fact that, when
acetic acid was added to the fibrous connective tissue, numerous small corpuscles, gene-
lally termed the nuclei of the texture, previously hidden by the fibrillated bundles, came into
view, whilst at the same time the fibrillar disappeared. But the connection of these corpus-
cks with each other, through anastomosing processes, was not at that time recognized. In
some of the more delicate varieties of connective tissue, met with in the young of the higher
Tertebrata, and in the more strongly developed forms in some of the lower vertebrata, as in
the skin of certain fish, both cells and fibres may be seen to coexist, without the addition of
any reagent, though it does not necessarily follow that the cells in these cases possess a ra-
diated and anastomosing arrangement. In the denser and more compact forms — tendons,
ligaments, fasciae — the bundles of fibres are so closely arranged, that the cellular element is at
fint sight entirely concealed by them. It is only aAer boiling, or the application of strong
scidi, that the cell network can be detected. Forster (Virchow*s Archiv, 1859, 18th vol.)
has succeeded by digesting sections of dried tendons and other connective structures in con-
centrated nitric acid, and then placing glycerine around the sections, not only in demonstrat-
ing the existence of the radiated arrangement of the cells, but even in isolating them. Br.
^le, from his inquiries into the structure of the tissues, has, in the Gulstonian Lectures for
IWl, arrived at opinions differing from those of Virchow. He regards the system of anas-
tomosing cella, not as a tubular system, but filled with a soft substance, "germinal matter,"
<>o which the growth and maintenance of the whole texture depends.
There is still considerable difiiculty in deciding whether the yellow elastic fibre is a
cellalaror intercellular development. Bonders (Zeitsch. f. Wissen, Zool. iii), and Virchow
(Cellular Pathologic) hold that it is derived from peculiar chemical changes in and con-
(^eosBtion of the walls of the connective-tissue cells themselves. H. Moller (Bau der Mo-
len, S. 62), Henle (Canstatt, 1851), and more recently Kolliker (Op. cit.), on the other hand,
f^gard it as produced by peculiar changes in the fibrillar gelatine-yielding substance be-
tween the cells, so that, like the fibrous bundles, it is an intercellular, and not a cellular,
«riicture.
146 HEALING BT IMMEDIATE UNION.
intention ; but, since that term has been applied more recently to
another mode of healing, I have adopted the term *' immediate union"
from Dr. Macartney, who, so far as I know, was the first to observe
clearly that the healing of wounds may be effected " without any inter-
vening substance, such as blood or lymph."* He says : " The circum-
stances under which immediate union is effected, are the cases of incised
wounds that admit of being, with safety and propriety, closely and im-
mediately bound up. The blood, if any be shed on the surface of the
wound, is thus pressed out, and the divided bloodvessels and nerves are
brought into perfect contact, and union may take place in a few hours;
and as no intermediate substance exists in a wound so healed, no mark
or cicatrix is left behind.
" We have familiar examples of this mode of healing in slight cuts
received on the fingers, which, after being bound up, if no inflammation
be induced, perfectly heal without the individual having any unpleasant
sensation in the part after the moment of the infliction of the wound.
A case has been lately communicated to me, of a considerable cut of
the hand having been cured by this mode of direct union, without any
sensation of pain, in the short space of four or five hours."
It is singular that Dr. Macartney should speak of the process of im-
mediate union occurring in so few and very trivial instances as these ;
for it seems certain that many even very large wounds are usually, in
favorable circumstances, thus healed. The characteristics of this mode
are, that the divided parts, being placed in exact contact, simply con-
join or reunite ; no blood or new material is placed between them for a
connecting bond, and no sign or product of inflammation is present.
All these characters meet in such cases as the favorable union of flaps
of skin, which have been reflected from the subjacent parts, and are
then replaced or transferred to some other adjacent wounded surface.
The instances in which I have best observed it have been after
wounds reflecting portions of the scalp, and after operations for the
removal of the mammary gland. In these operations, as you know, the
usual proceeding is to remove some of the skin, including the nipple,
and to uncover the rest of the surface of the gland by reflecting from it
an upper and lower flap of skin. Then the gland being removed, these
flaps, which are often of considerable extent, are laid down upon the
parts on which the base of the gland rested, chiefly upon the fascia over
the great pectoral muscle.
One of the first specimens I examined well illustrated the healing
that may now ensue. It was taken from a woman thirty-three years
old, whose breast and several axillary glands were removed for cancer.
Her general health seemed good, and all went on well after the opera-
tion. The flaps, which were of course very large, had been carefully
laid down, strapped with isinglass plaster, and well tended. They ap-
* Treatise on Inflammation, p. 49.
HEALING BY IMMEDIATE UNION. 147
peared to unite in the ordinary way, and there remained only a narrow
space between their retracted edges, in which space granulations arose
from the pectoral muscle. Three weeks after the operation these were
making good progress towards cicatrization ; but erysipelas and phle-
bitis ensued, and the patient died in four or five days.
. I cut oflF the edges of the wound with the subjacent parts, expecting
to find the evidences of union by organized lymph, or, possibly, blood.
But neither existed ; and the state of parts cannot be better described
than by saying that scarcely the least indication remained of either the
place where the fiap of skin was laid on the fascia, or the means by
which they were united. It was not possible to distinguish the relation
which these parts held to each other from that which naturally exists
between subcutaneous fat and the fascia beneath it. There was no
unnatural adhesion ; but, as the specimen, which is in the Museum of
St. Bartholomew's, will still show, the subcutaneous fat which did lie
over the mammary gland was now connected with the fascia over the
pectoral muscle, just as (for example) the corresponding fat below the
clavicle is naturally connected to the portion of the same fascia that
lies there. The parts were altered in their relations, but not in their
structure. I could find small points of induration where, I suspect,
ligatures had been tied, or where, possibly, some slight inflammation
had been otherwise excited ; and one small abscess existed under the
lower flap. But with most careful microscopic examination, I could
discover no lymph or exudation-corpuscles, and only small quantities of
what looked like the debris of such oil-particles or corpuscles of blood
as might have been between the cut surfaces when the flaps were laid
down. In short, we cannot otherwise more minutely describe this
healing than by the term "immediate union :" it is immediate at once
in respect of the absence of any intermediate substance placed between
the wounded surfaces, and in respect of the speed with which it is ac-
complished.
Opportunities of examining wounds thus healed being rare, I made
three experiments on rabbits (with my friend Mr. Savory), and found
the description I have just given quite confirmed. A portion of skin,
which my extended fingers would just cover, was raised from the back
of a rabbit, replaced and fastened down with a few sutures. Three
days afterwards the rabbit was killed. The edges of the wound were
slightly retracted, and the space between them was covered with scab
for about half an inch under the edge of the replaced flap of skin, the
tissue was inflamed and infiltrated with exudation-matter ; but beyond
this no trace of the injury or of its healing could be seen. The parts
appeared as they had appeared before the operation. Even the micro-
scope could detect only a slight infiltration of inflammatory matter,
which one might certainly ascribe to the wound being open at its edges,
and to some hairs having by accident been inclosed under the flap when
it was replaced.
I
148 HEALING BT IMMEDIATE UNION.
Of course, it is only from such examinations as these after death,
that we can speak certainly of the absence of inflammation and of all
intermediate uniting substances; yet conflrmatory evidence may be
obtained from the examination of any such wound during life, — I mean
in any such case as that of a flap of skin raised up, then laid down on
the subjacent wounded surface, and there uniting favorably ; or in any
case of that kind of plastic operation in which a flap is raised, and then
made to slide to some further position. In such cases, with favorable
progress, no sign of inflammation is observed ; though, if the skin were
in even a small degree inflamed, it could scarcely fail to be manifested
by the ordinary appearances of redness and heat. If the flap be pressed,
no fluid oozes beneath its edges (I speak, of course, of only such cases
as are making favorable progress) ; and after one or two days, accord-
ing to the extent of the wound, the flap will move on the subjacent
parts, not with the looseness of a part separate from them, nor with the
stiffness of one adherent through inflammation, but with the easy and
pliant sliding which is peculiar to the natural connection of the skin
with the subjacent fascia.
Such is the nature of "immediate union ;** the best imaginable pro-
cess of healing. Two conditions appear essential to it : first, exactness
of the coaptation of the wounded surfaces ; and secondly, the absence
of all inflammatory process.
To obtain the former, the simple replacement of the raised pieces of
skin may sometimes be sufficient. But there is a class of cases to which
this mode of healing is peculiarly applicable, and in which more than
this may be required ; I refer to the removal of the large subcutaneous
tumors, — fatty tumors and the like, — where, after the operation, large
cavities are left, and commonly left to granulate. In these cases I
believe that modern surgery does not often enough employ the older
method of carefully and softly padding the parts, and of so bandaging
them that the exposed surfaces may be held in contact for the one, two,
or three days necessary for immediate union. Many surgeons, I know,
commonly employ these means, but by many they arc avoided, through
fear of exciting inflammation by overheating the parts, or hindering
the discharge of secreted fluids. Doubtless, no single rule of manage-
ment would be safe ; but I think, with regard to this fear of exciting
inflammation, it need not be entertained, if the means I have alluded
to be employed only during the first two or three days after the inflic-
tion of the wound. For one may generally observe that for at least
two or three days after such an injury as an amputation, the raising of
a flap of skin in a removal of Ihe breast, or the like, scarcely any repara-
tive process appears in the parts that are kept from contact ; no granula-
tions are formed, no pus secreted, only a little serous-looking fluid oozes
from them. Now, during this calm, which would certainly not be dis-
turbed by the parts being softly padded and kept in perfect rest, the
immediate union may be accomplished. If through any untoward cir-
HEALING BT PRIMARY ADHESION. 149
cumstance, it be not in this period completed, its occurrence is, I believe,
impossible, and then the means more appropriate for other methods of
healing may be employed.
The attainment of the other necessary condition, the absence of in-
flammation, is quite consistent with these means for insuring perfect
and continued contact of the wounded surfaces. How the condition is
to be fulfilled I need not say ; the means are some of those that are
commonly laid down for preventing inflammation from being as, it is
said, more than is necessary for the union by the first intention ; and
the best of them are temperance, rest, and uniform temperature. The
necessity of observing them will appear the greater, if it is remembered
that what is wanted for immediate union is, not a certain undefined
slight degree of inflammation, but the complete absence of inflammation ;
for the probability of the occurrence of immediate union may be reckoned
as being in an inverse ratio to the probability of inflammation occurring
in the time necessary for its accomplishment.
The second mode of repair that I enumerated is that by primary ad-
henon.
This is the process which Mr. Hunter named union by adhesion, or
union by the adhesive inflammation. My reasons for preferring the
term "primary adhesion'* will presently appear. He says, "Where
the former bond of union [i, e.y the union by blood or by the first in-
tention] is lost in a part, to produce a new one a second operation takes
place, namely, inflammation.*'* Observe how carefully Mr. Hunter
distinguishes the case in which inflammation ensues, from that in which
none is necessary : and presently after, — " If the divided parts are al-
lowed to remain^ till the mouths of the divided vessels are entirely shut,
inflammation will inevitably follow, and will furnish the same materials
for union which are contained in extravasated blood, by throwing out
the coagulated lymph ; so that union may still take place, though some
time later aft«r the division of the parts. This inflammation I have
called the adhesive.** On this sentence, Mr. Palmer, expressing the
opinion entertained by all the pathologists of some twenty years ago,
says : " It is now generally considered that union by the first intention
and adhesive inflammation are essentially the same processes, modified
by the degree of inflammation. Union by the first intention is uniformly
attended with some degree of pain and swelling, together with increased
heat and vascularity, which, taken conjointly, constitute the definition
of inflammation.** And again: "According to the modern views, the
modes of union above detailed [i. e., the modes of union included by Mr.
Hunter under the union by the first intention] are always accompanied
by adhesive inflammation The parts are united, not by the ex-
travasated blood becoming vascular, but by the eS'usion and organiza-
tion of coagulable lymph.**
* Works, vol. iii, p. 263.
150 HEALING BY PRIMARY ADHESION.
After what I have said respecting the process of immediate onion, it
may appear that Mr. Hunter was more nearly right than his successors.
It would he an instructive piece of the history of surgery, to show,
exactly, how his truth, being mixed with error, came, therefore, to be
thrown away, and to make room for an error which had less truth
mixed with it. The stages of transition in opinions seem to have been,
that, first, suflBcient reason was found for disbelieving Hunter's state-
ment, that blood forms the bond of union by the first intention ; then,
as it was assumed that there must always be some intermediate bond,
this, it seemed, could be none but coagulable lymph. Now, coagulable
lymph being known only as the product of inflammation, it followed
that inflammation must be necessary for the healing of every wound ;
and then there ceased to be any distinction between the union by the
first intention and the union by adhesion ; both alike seemed to be the
result of lymph, the product of inflammation, being exuded between the
wounded surfaces, and united to them both.
Typical examples of union by primary adhesion may be watched in
the cut edges of skin that are brought near together. When the cut
surfaces are not in exact contact, the wound is exposed, and lymph is
formed, and fills up the space; or, when they are in contact, the
sutures, or other means employed to keep them so, excite inflammation
enough for the production of some lymph between them. The lymph
is simply laid on the cut surfaces ; and scarcely any is infiltrated in the
tissues. Organizing itself, and becoming vascular, it connects the two
edges or surfaces, and, finally, forms between them a thin layer of con-
nective tissue, on the surface of which, if it be exposed, a very delicate
layer of cuticle is developed. The smooth shining surface of this cuticle
gives the peculiar character of the scar, and one that scarcely changes,
except in the alteration of apparent color, when the new material
becomes less vascular.
The lymph eff'used in the healing by primary adhesion always, so far
as I know, develops itself with formation of nucleated cells, and, doubt-
less, the Avhole process is very similar to that of the adhesion of inflamed
serous membranes.
It may be very quickly accomplished. A boy died eighty hours
after receiving a lacerated wound of the abdomen ; and, for forty-eight
hours of these eighty, he was so manifestly dying, that I think no
reparative process could have been going on. A portion of the edges
of the wound was united with lymph, which presented well-marked
cells, like those of granulations, and contained looped bloodvessels full
of blood.
But it may be accomplished more quickly than in this case. In a
rabbit that I operated on as for a hare-lip, I found, after forty-eight
hours, the edges of the wounds partially, but firmly, united by lymph,
many of the cells of which were already elongated, in such development
as I have already described. Or, even more quickly than in this in-
I
i
HEALING BY GRANULATION. 161
«
stance : if a small abscess be opened, and the edges of the opening are
not gaping or inverted, they may be found united, except at the middle,
within twenty-four hours. I have seen them so united, with a distinct
layer of soft, pinkish, new substance, in a wound made seventeen hours
previously.
There are no cases in which the process of primary adhesion can be
better observed than after operations for hare-^ip. The inner portions
of the wounds made in them may be healed by the immediate union,
when the surfaces have been in exact coaptation ; but the edges of the
skin and mucous membrane seem always united by the adhesive inflam-
mation, for a scar is always visible — a scar formed by the lymph or-
ganized into connective tissue and epithelium, and one which, as well as
any, shows how little of assimilative force can be exercised by adjacent
tissues ; for narrow as it may be, it does not become quite like the
adjacent skin, nor, like it, bear perfect epidermis and hair.
The history of union by primary adhesion cannot be conveniently
completed till an account has been given of the healing by granulation
and by secondary adhesion. Of these I will next speak ; now I will
only say of this union by primary adhesion, that it is less desirable
than the immediate union, because Ist, it is, probably, not generally so
speedy ; 2dly, it is not so close, and a scar is always formed by the
organization of the new matter ; and 3dly, the formation of lymph- or
exudation-cells is a process so indefinitely separated from that of the
formation of pus-cells, that union by primary adhesion is much more
likely to pass into suppuration than any process is in which no lymph
is formed.
In describing the modes of healing by granulation and by secondary
adhesion^ I shall venture again to take my account from certain typical
examples : such as cases in which, after amputation of a limb, the sur-
faces of the wound are not united by either of the means already de-
scribed, but, as the expression is, are left to " granulate ;*' or such
cases as the removal of a breast, and subsequent suppuration of the flaps
and the exposed fascia ; or such as wounds into inflamed parts, when
the edges gape wide asunder, and the spaces left between them are
filled up with granulations. These may serve as examples of a process
which, although in all cases it may preserve certain general features of
similarity, is yet in detail almost infinitely diversified, and often so
inexplicably, that any more than a general account of it might fill
volumes.
.Granulations will generally arise on all wounded surfaces that are
left open to the air and are not allowed to dry. They will do so whether
this exposure be continued from the first infliction of the wound, or
commence after the edges, which have been brought together, have
keen again forced asunder by the swelling of the deeper-seated parts,
or by hemorrhage, or secretion of fluid, between them. Exposure of
HEALING BT GRANULATION. 153
tent of the wounded part, and the general condition of the body. In a
cut or sawn hard bone, about ten days will generally elapse before any
change is manifest ; in cancellous bone the change ensues a few days
more speedily : on the under surface of a large flap of skin, with sub-
cutaneous fat, three days may thus pass without change ; on the cut
or excoriated surface of the more vascular part of the skin, two days
or three.
These periods of repose after severe injury are of equal interest in
physiology and in surgery ; but in the former it is chiefly the interest
of mystery. Observations on injuries of the frog*s web* make it pro-
bable that the blood is stagnant in the vessels for some little distance
from the wound during several days after the injury : but why it is so,
and what are the changes ensuing in and about it preparatory to its
again moving on, we cannot quite tell. The interest to the surgeon
watching this period of repose is more practical. The calm may be
the brooding-time for either good or evil ; whilst it lasts the mode of
union of the wound will, in many cases, be determined : the healing
may be perfected, or a slow uncertain process of repair may be but
just begun ; and the mutual influence, which the injury and the patient's
constitution are to exercise on one another, appears to be manifested
rery often at or near the end of this period. Moreover, in open wounds,
the time at which, on each tissue, granulations are produced, is deter-
mined by this calm ; for they begin to be distinctly formed at its end.
Thus, on a stump, after a circular amputation, one may find the mar-
gin of the skin and the surface of the muscles well covered with granu-
lations, while the surface of the fat reflected with the skin is barren of
them, and the sawn walls of the bone are dry and bare. But from the
sawn end of the medullary tube there may already protrude a florid
mushroom-shaped mass of granulations, overhanging the adjacent walls ;
as if parts in which nutrition is habitually carried on under restraint,
within hard and rigid boundary-walls, were peculiarly apt to produce
abundant organizable material as soon as they are released.f Gene-
rally, also, the granulations springing from these different tissues observe
the same order in their rate of development as in their first appearance.
Those that first take the lead keep it, or, for a time, increase it.
But suppose the period of calm after the violence of the injury to
be well over-past. How does the right process of repair set in ? Ap-
parently, first of all, by the supply of blood to the injured part being
increased.
* See especiallj those detailed by Mr. Travers in his Essay on Inflammation and the
Healing Process: and those by Mr. Wharton Jones, On the State of the Blood and Blood-
Tessels in Inflammation.
t One may sometimes observe a similar fact in the growth of granulations out of the very
centre of the cat end of a divided tendon, while its margins are unchanged. The abun-
dant growth of substance like brain, covered with granulations, in cases of hernia cerebri,
is of the same kind.
11
154 HEALING BY GRANULATION.
The experiments on the webs of frogs, to which I haye already re-
ferred, have shown that, immediately after the infliction of an injury
the blood in the adjacent parts remains for some days quite stagnant;
and we may believe the same occurs, but for a shorter time, in our own
case. During this stagnation, materials may ooze from the yesselB,
enough to form the glazing of the wounded surfaces of certain parts ;
but before granulations can be formed, the flow of blood must again
begin, and its supply must be increased by enlargement, and perhaps
by multiplication, of the vessels in the injured part. We cannot often
see this increase so well in soft parts as in bone exposed after injury.
If, in this condition, compact bone be closely watched, there may be seen,
two or three days before the springing up of granulations, rosy points
or minute blotches, which gradually deepen in their hue, and become
larger. From these, presently, granulations will arise. The same pro-
cess may be well seen when a portion of the skull has been exposed, as
by suppuration under the pericranium. In such a case, which I watched
carefully, nearly one-third of the upper part of the skull was bared, and
it became dry and yellowish, and looked quite lifeless; but after some
days a few rosy points appeared on its surface, and these multiplied and
enlarged, and from each of them granulations grew up, till the whole
surface of the skull was covered. I watched them nearly every day,
and it seemed evident, at least to the naked eye, that, in all cases, an
increased supply of blood preceded the production of the new material
from which granulations were to be formed.
Doubtless just the same happens in soft parts as in bone; so that it
may be stated, generally, that the first visible change that ensues after
the period of calm, tlie period of incubation, as it is called, is an in-
creased supply of blood to the parts in which repair is to ensue. This,
probably, corresponds exactly with the increased afflux of blood which
ensues in inflammation ; and Mr. Traverses and other observations on the
healing of the frog's web, make it nearly sure that this increased afflux
is attended with slower movement of the blood, or at first even with
stagnation of the blood in the minute vessels nearest to the cut edges or
surface.
Of the force by which this increased afflux of blood is determined, I
believe that as yet no sufficient explanation can be rendered ; but the
fact serves to show that the ordinary process of granulation is, in its
commencement, morbid. It is beneficial indeed, in its end or purpose,
but is morbid in its method, being comparable with the process of in-
flammation more than with any of those that are natural to the body.
The process of granulating displays, I think, two points of resemblance
to inflammation, and of dissimilarity from natural processes : namely,
1st, that the increased quantity of blood in the part producing gra-
nulations moves more slowly than in health ; while in the naturally in-
creased supply its movement is not retarded; and 2dly, that the
increased supply of blood precedes the increased production of material.
HEALING BY GRANULATION. 155
For, in the discharge of nataral functions, the increased supply of blood
to a part appears always to be a- secondary event, the consequence of
some increase in the formation of the part. As, in the embryo, many
parts form themselves before blood appears, and the growth of these and
Other parts always a little precedes the proportionate supply of blood to
them ; so always, subsequently, the increase or diminution of growth,
or any other organic act, appears to precede, by some small interval,
the proportioned change in the supply of blood. But with unnatural
and morbid processes it appears to be usually different : in these, with
inflammation for their type and chief example, the increased afflux of
blood precedes the increased production of material to be organized, and
the decrease of blood precedes the decrease of organic processes.
That which next follows, after the increased afflux of blood, is the
effusion of the material that is to be organized into granulations. This
18 added to, or, perhaps, displaces, the glazing that already exists upon
some surfaces ; and where none such exists, as on fat or bone, the new
material is accumulated on the bare surface of the wound. No account
of the process of effusion, so far as it is visible to the naked eye, can be
better than Mr. Hunter's (iii, 491). " I have often been able,'* he says,
** to trace the growth and vascularity of this new substance. I have
seen upon a sore a white substance, exactly similar, in every visible
respect, to coagulating lymph. I have not attempted to wipe it off, and
the next day of dressing I have found this very substance vascular; for
by wiping or touching it with a probe it has bled freely. I have ob-
served the same appearance on the surface of a bone that was laid bare.
I once scraped off some of the external surface of a bone of the foot, to
see if the surface would granulate. I remarked, the following day, that
the surface of the bone was covered with a whitish substance, having a
tinge of blue ; when I passed my probe into it I did not feel the bone
bare, but only its resistance. I conceived this substance to be coagu-
lating lymph thrown out from inflammation, and that it would be forced
off when suppuration came on ; but, on the succeeding day, I found it
vascular, and appearing like healthy granulations.**
To this account little can be added more than the microscope has
shown. In the minute structure of granulations, or, at least, of such
growths of new substance as present all the characters that we imply
by that term, — the bright ruddy texture, the uniformly granulated free
surface, the succulency and abundant supply of blood, — in these we
may discern two varieties, corresponding with the varieties of lymph
that I have already spoken of. In subcutaneous injuries or diseases,
granulations sometimes form which develop themselves into connective
tissue, through nucleated blastema. So I found in a case of simple
fractiire in which the ends of the bone remained long disunited ; they
were inclosed in a cavity formed by condensation of the surrounding
tissaes, bat containing no pus, and were covered with a distinct layer
166 HEALING BY GRANULATION.
of florid granulations. It was just such a case as that ^hich Mr. Hun-
ter had in view, and preserved,* as an instance of the formation of
granulations without suppuration, in the repair of subcutaneous frac-
tures and other injuries.
But in by far the greater proportion of cases, granulations are only
formed in exposed injuries : and in these, they consist of cells that,
together with their intercellular substance, may develop themselves
into connective tissue : and of such as these I will now exclusively
speak.
Cells upon cells, such as I have already described (p. 140), are
heaped up together in a layer from half a line to two lines, or, rarely,
more in thickness, without apparent order, and connected by very little
intermediate substance. (Figs. 14 and 19.) Singly they are colorless,
but in clusters they are ruddy even independent of the bloodvessels.
In granulations that are making healthy progress — in such as, after
three or four days* growth, are florid, moist, level, scarcely raised above
the surrounding tissues, uniformly granular, or like a surface of minute
papillae,— one can conveniently trace the cells in various stages, ac-
cording to the position they occupy. The deeper seated ones are
always most advanced, and often much elongated and fusiform ; while
the superficial ones are still in a rudimental state, or, near the edges of
the granulating surface, are acquiring the character of epithelial cells.
The connective tissue thus constructed by the development of the
granulation-cells, and their intermediate substance, finally assumes all
the characters of the natural examples of that tissue. Thus it is found
in the thin layer of substance of which scars that are formed in the
place of granulating wounds, are composed. After some time, elastic
tissue is mingled with the white fibrous ; but this, as I have already
said, appears to be effected by a later process. I found, in one case,
no elastic tissue in scars that had existed, the one twelve months, the
other eighteen months ; but in scars several years old I have always
found it.
The cuticle, also, that forms on granulations, gradually approximates
more nearly to the perfect characters, and, like the connective tissue
that it covers, presents the interesting fact of adaptation to the pur-
poses of the part on which it is placed. Thus, in granulating wounds
or ulcers on the sole of the foot, one may often see that, from the first,
the new cuticle is more opaque and thicker than it is on other parts on
which the natural cuticle, in adaptation to the protection required from
it, is naturally thinner ; and let it be observed that this peculiar forma-
tion of the new cuticle is in adaptation to conditions not yet entered
upon. It justly excited the admiration of Albinusf when he saw in
the foetus, even long before birth, the cuticle of the heel and palm
thicker than those of other parts ; adapted and designed to that greater
* College Museum, No. IC. f Annotationes Academics.
HEALING BY GRANULATION. 157
friction and pressure, to which, in future time, they would be exposed.
It is the same when, in adult life, the new cuticle is to be formed on
the same parts. While it is forming, all pressure and all friction are
kept away, yet it is constructed in adaptation to its future exposure to
them. Surely such a provision is, beyond all refutation, an evidence
of design ; and surely in this fact we may discern another instance of
the identity in nature and in method of the powers that are put in
operation in the acts of first construction and of repair.
But before I end this lecture, let me add, that although one may so
clearly trace, in the development of the granulation-cells, an interme-
diate substance, and in the end which they achieve by the formation of
connective tissue and cuticle, an imitation of the natural processes and
purpose of the corresponding developments in the embryo, yet is there a
remarkable contrast between them, in regard to the degrees in which
they are severally liable to defect or error. We can scarcely find ex-
amples of the arrests or errors of development of mere structure in the
embryo ; but such events are quite common in the formation of granu-
lations, as well as of all other new products. All the varieties in the
aspect of granulating wounds and sores, which the practised eye can
recognize as signs of deflection from the right way to healing, are so
many instances of difi'erent diseases of the granulation-substance ; dis-
eases not yet enough investigated, though of much interest in the study
of both the healing process and the organization of new products in
inflammation.
A comparatively few observations enable one to trace morbid condi-
tions of these new structures, closely answering to those long known in
the older and more perfect tissues. Thus, one may find simply arrested
development of granulations ; as in the indolent healing of wounds and
ulcers, whether from locally or generally defective conditions. Herein
even years may pass, and the cells will not develop themselves beyond
one or other of their lower forms. There is probably a continual mu-
tation of particles among such cells, as in common nutrition, or they
may increase, as in growth ; but no development ensues, and the wound
or the ulcer remains unhealed.
In other cases, the cells not only do not develop themselves, but they
degenerate, becoming more granular, losing the well-marked characters
of their nucleus, and acquiring all the structures of the pus-cell ; thus
are they found in the walls of the fistulae and sinuses. Or, worse than
this, the granulation-cells may lose all structure, and degenerate into a
mere layer of debris and molecular substance. Thus they may be found
on the surface of a wound for a day or so before death in exhaustion, ^
or in erysipelas, or fever ; and in this state they are commonly ejected
when a granulating wound ulcerates or sloughs.
With more active disease, granulations become turgid with blood, or
cedematous : such are the spongy masses that protrude beyond the open-
ings leading to diseased bone. Or, they inflame ; and abundant large
158 FORMATION OF NEW BLOODVESSELS.
inflammatory granule-cells are found among their proper structures.
Or they suppurate internally, and purulent infiltration pervades their
whole mass.
All these are among the many hindrances to healing : these are the
dangers to which the healing by granulations is obnoxious : it is the
proneness to these things that makes it even slower and more insecure
than, in its proper course, it might be. And these are all instances of
a class of changes which it is most important to study for exactness in
morbid anatomy, — I mean, the diseases of the products of disease.
LECTURE X.
THE PROCESSES OF REPAIR OF WOUNDS.
With the structural development of the granulation-cells and inter*
mediate substance into connective tissue and cuticle, as described in the
last lecture, there coincides a chemical change which seems to be the
contrary of development; for the granulation-substance, being con-
verted from albuminous into horny and gelatinous principles, becomes,
in chemical composition, less remote than it was from the constitution
of inorganic matter. At its first effusion, the reparative material has
the characters of a fibrinous principle ; afterwards, when in the form of
granulations and of young connective tissue, its reactions are so far
altered that it presents the characters of pyine, a somewhat indefinite
principle, yet an albuminous one ; finally in its perfect development,
the new-formed connective tissue is gelatinous, and the epithelium ap-
pears to be like other specimens of horny matter.
These changes are in conformity with what appears to be a general
rule ; namely, that structures which are engaged in energetic develop-
ment, self-multiplying, the seat of active vital changes, are generally of
the highest organic chemical composition ; while the structures that are
already perfect, and engaged in the discharge of functions such as are
attended with infrequent changes of their particles, are as generally of
lower composition. The much higher chemical development (if I may
so call it) of the blood, than of the greater part of the tissues that are
formed from it, is a general instance of this : in it albumen and fibrine
predominate, and there is no gelatine ; in the tissues gelatine is abun-
dant, and fatty matter : and both these, through their affinities to the
saccharine and oily principles, approach the characters of the lower
vegetable and inorganic compounds.
The granulation-substance is a good instance in point : while lowly
developed, but in an active vegetative life, it is albuminous ; when per-
fect in its development, its perfected structures are gelatinous or horny.
FORMATION OF NEW BLOODVESSELS. 159
In this state its particles have probably a longer existence ; they ex-
change a brief life of eminence for longevity in a lower station.
I have spoken hitherto of the development of only those structures
which form the proper material of granulations, and of the scars that
remain after the healing of wounds. But commensurately with these,
bloodvessels, and, perhaps, also, nerves, are formed. Of these, there-
fore, I will now speak.
In the last lecture I referred to the changes that ensue in the circu-
lation of a wounded part. At first, it appears that the blood stagnates
in the vessels immediately adjacent to the wound. This is evident in
the wounds made in frogs* webs, and is most probable in the case of
wounds in our own tissues ; for else we could hardly understand the
total absence of bleeding from a surface on which, as in every large
wound, myriads of small vessels must be cut, and lie exposed. But
after a time, of various duration in the different tissues, the movement
of the blood is renewed, though not to its former velocity ; the vessels of
the wounded parts enlarge, and they all appear more vascular. Then
the material of granulations, already in part effused, accumulates, and
very soon blood and bloodvessels appear in this material.
By what process are these new vessels formed ? Mr. Hunter's opi-
nion was (and it is still held by many), that both the blood and its ves-
sels form in the granulation-substance, as they do in the germinal area
of the chick ; and that, subsequently, they enter into communications
with the vessels and blood of the part from which the granulations
spring. This is certainly not proved: although the development of
the new vessels is according to a method that is equally natural.
In embryos, we may discern three several modes according to which
bloodvessels are formed, a good example of the manifold ways by which,
in development, the same end may be reached. In the first and earli-
est method solid cylinders of round cells, lying compactly together, are
formed in the area vasculosa, in which cylinders changes then take
place. The cells in the central part of the cylinder loosen and become
converted into blood-corpuscles, or, as, Billroth* appears to think, their
membranes disappear, and their contents only constitute the blood-cor-
puscles. The membranes of the cells on the outer parts of the cylinder
coalesce and form the membranous wall of the vessel, which may after-
wards be developed into the more complicated structures of the heart,
or larger bloodvessels. To increase the extent and number of vessels
that mast be added in adaptation to the enlargement and increasing
complexity of the embryo, two methods are observed. In one, primary
cells, in the interspaces of vessels already existing, enlarge and elongate,
and send out branches in two or more directions, so as to assume a stel-
late form. These branches are hollow : and while some of them are
* Untenuchungen Uber die Ent wick lung der Blutgef&sse; Berlin, 1856.
160
FORMATION OF NEW BLOODVESfi^BLS.
directed into anastomosis with each other, others extend towards, and
open with dilatations into, the vessels already formed and carrying
blood. Then, these fine branches of each cell becoming larger, while
the main cavity of the cell, from which they issued, attenuates itself,
they are altogether transformed into a network of ti^bes of nearly uni-
form calibre, through which the blood, entering by the openings of
communication with the older vessels, makes its way. Thus the wide
network formed in the primordial circulation is subdivided into smaller
meshes, and each part receives a more abundant supply of blood. Bill-
roth has described a kind of vascular formation, which may be considered
as a modification of the above method. He has seen long spindle-like
cells lie with their long axes parallel to each other and close together,
but not in contact, so that a fine canal existed between them, which
constituted the canal of the newly formed vessel, the wall being formed
by the spindle-like cells themselves. From these cells new blood-cor-
puscles proceeded into the vessel, as in the first method of vascular
formation. This process he has noticed not only in embryonic tissues,
but also in granulations.
The other of these secondary modes of formation of new bloodves-
sels is, I believe, the most frequent mode in which bloodvessels are ever
formed for granulations, or for superficial deposits of lymph, adhesions,
and the like. The dia-
^ig- 16- gram is made from what
may be seen in the grow-
ing parts of the tadpole's
tail, and it accords with
what Spallanzani observed
of the extension of vessels
^^^^o^.^^c\ into the substance of the
i^*&(9 S.?-.<2> .3^ tail when being reproduced
after excision. Mr. Tra-
vers* and Mr. Quekett
watched the same process
in the new material formed
for the filling up of holes made in the frog*s web ; and the sanae is in-
dicated in the specimens illustrating the repair of similar wounds which
are in the College, from the Museum of the late Dr. Todd, of Brigh-
ton. There is, I think, sufficient reason to suppose that it is the
principal method for the supply of bloodvessels to any granulations, or
similar new productions. For, though the process in granulations or
in lymph cannot be exactly watched during life, yet every appearance
after death is consistent with the belief that it is the same as has been
traced in the cases I have cited, and I have never seen any indications
of either of the other methods of development having occurred.
* On Inflammation, and the Healing Process. See, also, on a similar formation, Virchow
in the WOrzburg Verhandlungen, B. i, p. 301.
FORMATION OF NEW BLOODVESSELS. 161
The method may be termed that by out-growth from the vessels al-
ready formed. Suppose a line or arch of capillary vessel passing below
the edge or surface of a part to which new material has been superadded.
(Fig. 16.) The vessel will first present a dilatation at one point, and
coincidently, or shortly after, at another, as if its wall yielded a little
near the edge or surface. The slight pouches thus formed, gradually
extend, as blind canals, or diverticula, from the original vessel, still
directing their course towards the edge or surface of the new material,
and crowded with blood-corpuscles, which are pushed into them from
the main stream. Still extending, they converge ; they meet ; the par-
tition wall, that is at first formed by the meeting of their closed ends,
clears away, and a perfect arched tube is formed, through which the
blood, diverging from the main or former stream and then rejoining it,
may be continuously propelled. Or a delicate thread-like process shoots
out from a vessel, which becomes connected either with corresponding
shoots from other vessels, or with processes from other cells. These
fine processes widen out, become tubular, and their cavities form canals
continuous with that of their parent vessel.*
In this way, then, are the simplest bloodvessels of granulations and
the like out-growths formed. The plan on which they are arranged is
made more complex by the similar out-growths of branches from adja-
cent arches, and their mutual anastomoses : but, to all appearance, the
whole process is one of out-growth and development from vessels already
formed. And I beg of you to consider the wonder of such a process ;
how, in a day, a hundred or more of such loops of fine membranous
tube, less than 7000^^ ^^ ^^ ^Q<^b ^^ diameter, can be upraised ; not by
any mere force of pressure, though with all the regularity of the sim-
plest mechanism, but each by a living growth and development, as or-
derly and exact as that which we might trace in the part most essential
to the continuance of life. Observe, that no force so simple as even
that of mere extension or assimilation can determine such a result as
this : for, to achieve the construction of such an arch, it must spring
with due adjustment from two determined points, and then its flanks
must be commensurately raised, and these, as with mutual attraction,
must approach and meet exactly in the crown. Nothing could accom-
plish such a result but forces determining the concurrent development
of two out-growing vessels. We admire the intellect of the engineer,
who, after years of laborious thought, with all the appliances of weight
and measure and appropriate material, can begin at points wide apart,
and force through the solid masses of the earth one tunnel, and can
wall it in secure from external violence, and strong to bear some pon-
derous traflic ; and yet he does but grossly and imperfectly imitate the
Divine work of living mechanism that is hourly accomplished in the
bodies of the least conspicuous objects of creation — nay, even in the
healing of our casual wounds and sores.
* Billroth, op. cit.
L
FOKHATION OF NEW BL0ODVEBBKL8.
Fig. 17.
The vonder of the proceBB is, perhaps, in some degree enhaooed by
the ereots that will follow what may seem to be an accident. When
the new vessel has begun to project, it Bometimes bnrsts; and the
diagram shows what then
will happen. I bare to
tliant Mr. Quekett for the
sketch, which he made while
assisting Mr. Trarera in the
examinations already cited.
The blood-corpuscles that i»-
sue from the ruptured pouch
or direrticnlum collect in an
uncertain mass within the
tissue, like a mere ecchymosie ; but, before long, they manifest a defi-
nite direction, and the cluster bends towards the line in which the new
vessel might have formed, and thus opens into the other portion of the
arch, or into some adjacent vessel. For this mode of formation from
vessels, the name of channelling seems more appropriate than that of
out-growth ; for it appears certain that the blood- corpuscles here make
their way in the parenchyma of the tissue, unconfined by membranous
walls. That they do so in a definite and purposive manner, though
their first issue from the vessel has appeared so accidental, may be due
to the fact that in the more regular development by out-growth, the
cells of the parenchyma concur
Fig. 18.
with the extension of the new
vessels, by clearing away from
them as they approach ; so that,
even before the out-growtb, the
way for it or for its contents
(should they happen to escape),
is, in some measure determined.*
The general plan of arrange-
ment of the bloodvessels in gra-
nulations, represented in the ad-
joining sketch, agrees with this
account of tbeir development by
out-growth. Some of Sir A.
Cooper's preparations in the
Museum of the Gollegef show
how the new vessels extend from
* Blllroih hii> deKribed anit flguted (p. 1^, PI. J, Fig.
thai recorded in ths lext. He, ai first, thought thai it
H).:
extra vaulimi, but
fuTther consideralion haa led liim, in Accordance with certain views which be etiteHBint
rospeoling tlie mode of furroation of bloOIl-co^pllscle^ to thirit Ihal liere, perbaps, a new
free formalion of colored biood-corpusclea, out of the coloriess-aliining hooiogeneous ceili of
the pad inliea place. Al the lame time he conreaaes the diHiculiy of understanding bow
they get into the circnlatioo.
t Noi. IS, 30, 35a.
FOBXATION OF NSW BLOODVESSELS.
the parts on which the graonlatioDB lie, in lines directed vertically
towards their surface, not often dividing, but cdmmunicating on their
way by frequent transverse or irregular branches. Of these branches,
some probably represent the loopa or arches successively formed in the
deepening layer of granulation -cells, while others must be formed by
offshoots from the sides and other parts of the several arches. Near
the surface of the granulations, at a very little distance below the outer-
most layer of the cells, the vessels communicate much more frequently,
and form their loops or terminal arches — arches of junction between the
outgoing and the returning streams of blood.
On the same plan are formed the vessels of the walls of abscesses
lined with granulations ; but here (at least in the specimens I have
been able to examine) the vertical vessels are not so long, and the
whole number of vessels is generally greater. I believe the vessels of
granulating ulcers are always similarly arranged ; so they are repre-
sented by Mr. Listen,* in a common ulcer ; so, also. Sir A. Cooperf
described them in granulations from an ulcerated scirrhous cancer; and
I have found the same general plan in the warty ulceration of soot-
cancer on the scrotum.
The new vessels formed in granulations possess a very simple struc-
ture." Their walls consist of a thin membrane in which nuclei are im-
bedded. Some of these nuclei are arranged longitudinally, others trans-
Tersely, to the axis of the vessels, and it is often noticeable that the
development of the tissues of the bloodvessels makes more progress than
that of the granulation-cells which they subserve.
Respecting the purpose of the supply of blood thus sent to granula*
tions, one traces, in the development of vessels, a series of facts exactly
answering to those in ordinary em-
bryonic development. Organiza-
tion makes some progress before
ever blood comes to the very sub-
stance of the growing part ; for
the form of cells may be assumed
before the granulations become
vascular. But, for their continu-
oua active growth and develop-
ment, fresh material from blood,
and that brought close to them,
is essential. For this, the blood-
vessels are formed ; and their size
and onmber appear always pro-
portionate to the volume and
rapidity of life of the granula-
tions. Ko instance would show
* Medioo-Cfairurgicnl Tranuclions, vol iiiii. p. f^^-
t Cualofus of the Paibological Muaenni of the College, toI. i, p. 1
Fig. 10.
164 FORMATION OF NEW BLOODY BSSBLB.
the relation of blood to an actively growing or developing part better
than it is shown in one of the vascular loops of a granulation, imbedded,
as this sketch shows it, among the crowd of living cells, and maintaining
their continual mutations. Nor is it in any case plainer than in that
of granulations, that the supply of blood in a part is proportionate to
the activity of its changes, and not to its mere structural development.
The vascular loops lie imbedded among the simplest primary cells, or,
when granulations degenerate, among structures of yet lower organiza-
tion ; and as the structures are developed, and connective tissue formed,
so the bloodvessels become less numerous, till the whole of the new
material assumes the paleness and low vascularity of a common scar.*
But, though the quantity of bloodvessels is determined by the state of
the substance they supply, the development of their tissues has no such
relation. It is often complete while the granulation-cells are rudimen-
tal, and remains long unchanged when they are degenerate. The fact
may be regarded as evidence of the formation of the new bloodvessels
by out-growth from the older ones ; for it is not probable that well-de-
veloped bloodvessels and ill-developed granulation-cells should be formed
out of the same materials at the same time.
Of the development of Nerves in granulations I know nothing ; I have
never been able to see any in either granulations or cicatrices. The ex-
quisite pain sometimes produced by touching granulations would indi-
cate the presence of nerves : but it would be more satisfactory to see
them ; for the force of contact, or the change that it produces, may be
propagated through the layer of granulations, and stimulate the nerves
beneath them, as contact with the exterior of a tooth excites the nerve-
filaments in its pulp. The sensibility that granulations seem to have
may, therefore, be really that of the tissues from which they spring.
Lymphatics do not exist in granulations. Professor Schroeder van
der Kolk has demonstrated them in false membranes by mercurial in-
jections (Fig. 35) :t but in a letter he tells me that they cannot, either
by these or by any other means, be traced in either scars or granulations;
and, he adds, *' they cannot be demonstrated in the skin, even in the
healthy state, except in the scrotum.**
The subject of suppuration should perhaps be considered now ; but
I had rather defer it till I have spoken briefly of the two remaining
modes of healing open wounds ; those, namely, by Becondary adhesioHj
and by scabbing.
* Billroth (Beitrage zur Path. Hist.) describes the group of cells situated around a capil-
lary loop on a granulating surface, as formed by the proliferation, by division of the nuclei,
of the adjacent connective-tissue corpuscles. C. 0. Weber (Entwicklung dee Eiters), re-
ferring to Fig. 19 in this Lecture, states that the delicate cells which surround the vascular
loops of a granulating surface are of a spindle-like shape, and are imbedded in a thick layer
of growing connective-tissue nuclei.
f Lespinasse, De Yasis Novis Pseudo-membranarum, figs, iii, v.
HEALING BT SEOONDAKT ADHESION. 165
The healing by secondary adhesion, or anion of granulations, has been
long and often observed ; yet it has been only casually described, and
having never been distinguished by a specific name, has not received
that attention to which its importance in practice seems to entitle it.
It occurs wherever surfaces of granulations, formed in the manner just
described, well-developed, but not yet covered with cuticle, are brought
into contact, and so retained at rest. As often as this happens, the
cells of which the surfaces are composed adhere together; vessels
passing through them form itiutual communications ; and the surfaces,
before separate, are connected ; out of the two layers of granulations,
one is formed, which pursues the normal development into connective
tissue.
In all its principal characters, therefore, the process of secondary ad-
hesion is like that adhesion for which, to mark at once their likeness
and their differences, I have suggested the term of primary. In the
primary adhesion, the layer of lymph, placed between the wounded and
bare surfaces, is probably formed equally and coincidently from both ;
and, being developed in the same manner as the granulations, of which
I have spoken, it probably receives vessels from both surfaces, and so
becomes the medium through which the vessels communicate and com-
bine the severed parts. In the process of secondary adhesion, the
superficial cells on the surfaces of two layers of granulations are placed
together, and receiving vessels from both combine them into one.
Mr. Hunter observed this process, and says of it, — '' Granulations
have the disposition to unite with one another when sound or healthy ;
the great intention of which is to produce the union of parts, somewhat
similar to that by the first intention, although possibly not by the same
means." And *'I have seen two granulations on the head, — viz., one
from the dura mater after trepanning, and the other from the scalp,
unite over the bare bone which was between them, so strongly, in twenty-
four hours, that they required some force to separate them, and when
separated they bled."*
In illustration of this process he put up a preparationf which in his
MS. Catalogue he describes as ^^ granulations under the skin in an ab-
scess in the leg, which were opposed by others on the muscles, and
which were to unite. Those under the skin only are saved and folded
towards each other, to show the opposition of two granulating sur-
faces."
There are several circumstances in which the healing by secondary
ftdhesion should be attempted. For example, in a case of ordinary am-
putation of the thigh, no immediate union, and no primary adhesion,
took place, after the operation, and the whole interior of the stump was
granulating. Had it been, as the expression is, ^Meft to granulate,"
or "to fill up with granulations," the healing process would have occu-
* Works, Tol. iii, p. 493. f Pathological Museum of the College, No. 27.
166 HEALING UNDER A SCAB.
pied at least a month or five weeks more, and would have greatly ex-
hausted the patient, already weakened by disease. But Mr. Stanley
ordered the stump to be so bandaged that the opposite surfaces of gra-
nulations might be brought into close contact : they united, and in a
week the healing of the stump was nearly perfected.
In all such cases, and I need not say that they are very frequent, the
healing by secondary adhesion may be attempted without danger, and
often with manifest advantage.
Again : Mr. Hunter operated for hare-lip, and no primary adhesion
of the cut surfaces ensued. He let them both granulate : then brought
the granulations together, as in the common operation, and they united,
and healed soundly.
Or, again : Mr. Skey, some time ago, operated for fissure of the soft
palate. The edges of the wound sloughed and retracted, and the case
seemed nearly hopeless ; but he kept in the sutures, and granulations
sprang up from the edges of the cleft, after the separation of the sloughs ;
they met in the mid-space of the cleft, and coalesced, and formed a per-
fect» scar.
Doubtless, cases like these are of no rare occurrence ; but I am in-
duced to mention them, as illustrations of a process of which the im-
portance and utility are not generally considered, and which is rarely
applied in practice.
In applying it, certain conditions are essential to success ; especially
that, — 1st, the granulations should be healthy, not inflamed, or pro-
fusely suppurating or degenerated, as those in sinuses commonly are :
2dly, the contact between them should be gentle but maintained ; and
perhaps they should be as much as possible of equal development and
age.
The healing of wounds by scabbing may be regarded, as Mr. Hunter*
says, as the natural one, for it requires no art. It is the method by
which one sees nearly all open wounds healed in animals : for in them,
even in the warm-blooded, it is difficult to excite free suppuration from
the surfaces of wounds : they quickly become coated with a scab, formed
of the fluids that ooze from them and entangle dust and other foreign
bodies ; and under such a scab the scar is securely formed.
In general, the scabbing process is eff'ected by some substance which
is eff'used on the surface of the wound, dries there, and forms a hard
and nearly impermeable layer. The edges of this substance adhere
over those of the wound, so as to form for it a sort of air-tight covering,
under which it heals without suppuration, and with the formation of a
scar, which is more nearly like the natural parts than any scars formed
in wounds that remain exposed to the air, and which does not, like
•them, contract, so as to produce deformity of the parts about it. ^
* Works, vol. iii, 262.
HEALING UNDER A SCAB. 167
The scab may be formed of either dried blood, dried lymph and
serum, or dried purulent fluid. Instances of the healing of wounds
under dried blood are not rare. It is especially apt to occur in the
cases of wounds in which a large flat surface is exposed, as after the
removal of the breast with much integument. The most remarkable
case of this kind is recorded by Mr. Wardrop.* The largest wounded
surface he ever saw, remaining after the removal of a diseased breast,
almost entirely healed under a crust of blood, which remained on for
more than thirty da^s.f *But the most common examples of healing
under blood-scabs are in small wounds, such as are made in bleeding,
or more rarely in some compound fractures. The excellent, though
nearly obsolete, practice of laying on such wounds a pad of lint soaked
in the blood, was a good imitation of the most natural process of their
repair.
If a blood-scab be not formed over a wound, or if such a one have
been detached after being formed, then at once a scab may be derived
from the serum and lymph that ooze from the surface of the wound.
Thus it is commonly with wounds in animals that are left to themselves,
and in many small wide-open wounds in our own case. Thus, also, I
imagine, thfe best healing of superficial burns and scalds is effected,
when the exposed surface is covered with cotton-wool or other sub-
stance, which, as the oozing fluids become entangled with it, may help
them to form a scab.
At a yet later period, the pus produced from exposed granulating
wounds may concrete on them, and they will heal under it excluded
from the air. Such a process may also ensue in the healing of ulcers,
and has been successfully imitated in Mr. Stafibrd's plan of filling deep
ulcers with wax.J In any case, the healing process is probably just
the same as that under scabs of blood or serum ; but I believe it has
not yet been exactly determined what are the changes that ensue in the
surface beneath the scab. So far as one can discern with the naked
eye, the wounded surface forms only a thin layer of cuticle on itself ;
no granulations, no new connective tissue, appear to be formed; the
raw surface merely skins over, and it seems to do so uniformly, not by
the progressive formation of cuticle from the circumference towards the
centre, as is usual in open wounds.
The healing of a wound by scabbing has always been thought a
desirable process ; and when one sees how quickly, by means of this
process, wounds in animals are healed, and with how little general dis-
turbance, one may well wish that it could be systematically adopted.
But to this there seems some hindrance. Many surgeons have felt, as
* lo bis Lectnre oo Surgery, in the Lancet for 1832-3, vol. ii.
t Mr. Henry Lee tells me that a similar case has occurred in his practice. An excellent
iostaoce of healing under blood-scabs is also related by Dr. Macartney (Treatise on Inflam-
mation, p. 208).
t On the Treatment of the Deep and Excavated Ulcer. 1829.
168 SUPPURATION.
Mr. Hunter did, that the scabbing process should be permitted much
oftener than it is, in the cases of both wounds and ulcers ; but none
have been able to lay down su£Gcient rules for the choice of the cases in
which to permit it. Probably, the reason of this is that, at the best,
in the human subject, the healing by scabbing is an uncertain process.
When the scab is oncp formed, and the wound covered in, it is neces-
sary that no morbid exudation should take place. Whenever, there-
fore, inflammation ensues in a wound or sore covered with a scab, the
exuded fluid, collecting under the scab, produces pain, compresses the
wounded surface, or forces oflF the scab, with discomfort to the patient
and retardation of the healing. I suspect that the many instances of
disappointment from this cause have led to the general neglect of the
process of scabbing in the treatment of wounds. The observance of
perfect rest, and of the other means for warding oflF inflammation, will,
however, make it a valuable auxiliary in the treatment of wounds,
especially of large superficial ones : in the treatment of small wounds,
collodion appears sufficient to accomplish all that scabbing would do :
and in deep wounds, fluid is too apt to collect under the scab.
Such are the several methods of healing observed after wounds of
soft parts ;* and in connection with them, two subjects remain to be
considered, namely, the process of suppuration, and that of the perfect-
ing of scars.
Respecting the process of suppuration, it cannot be necessary that I
should give a minute account of pus or of its general or chemical cha-
racters ; I will rather endeavor to show its relations to the healing pro-
cess, by illustrating the points of resemblance and of difference between
it and the materials of which granulations are formed.
Let me remind you that the formation of granulations is not neces-
sarily attended with the production of pus. I have already referred to
this fact in speaking of the formation of subcutaneous granulations,
such as are sometimes seen on the end of bones that do not unite, in the
ordinary way, after simple fractures. Mr. Hunter also expressly
describes these cases ; and the same kind of granulations without sup-
puration may be sometimes seen springing from the ulcerated articular
surfaces of bones, in cases of diseased joint without any external
opening, t
* I have not been able to recognize what Dr. Macartney named the modelling procest as
a method of healing distinct from that which ensues in the most favorable instances of
healing by granulations. I have, therefore, not enumerated it among the modes of healing;
yet it may occur in some conditions that I have not met with : I would not wish to impute
confusion to so good and independent an observer as Dr. Macartney.
f Dr. Redfern, from his researches into the changes taking place in ulceration of the ar^
ticular cartilages, was of opinion that pus had never been shown to bo formed from the
substance of the diseased cartilage. But the more recent observations of C. O. Weber
(Virchow's Archiv, B. xiii, 1858), with whom Barwell also coincides (Treatise on Diseases
of Joints), tend to the conclusion that pus in these cases may be derived from a multiplica-
tion of the nuclei of the cartilage corpuscles.
SUPPURATION. 169
However, when granulations are formed on an open wound, there is
always suppuration ; i. e., an opaque, creamy, yellowish- white or green-
ish-white fluid, pus, or matter, is produced on the surface of the granu-
lations. If the surface be allowed to dry, the pus may form a scab : if
it be kept moist, fresh quantities of pus are produced, till the surface
of the granulations is covered with the new cuticle. Granulations that
are skinned over no longer suppurate.
The essential constituents of pus are cells, and the liquid {liquor
fUTu) in which they are suspended. In pus produced during healthy
granulation, no other material than these may be found. But, often,
minute clear particles, not more than j^ Jd^) of an inch in diameter, are
mingled with the pus-cells. And, when the process deviates from health,
we find not only variations in the pus-cells, but multiform mixtures of
withered cells, molecular and fatty matter, free or escaped and shrivel-
led nuclei, blood-corpuscles, fragments of granular substance like shreds
of fibrine, and other materials. All these indicate defects or disease of
pus, corresponding with those of the granulations to which I have al-
ready referred.
Pus-cells, in their ordinary state, are represented in the adjoining
sketch.
Fig. 20.
® ®
A* B. (/.
As shown at A, they are spherical or spheroidal, or even discoid bo-
dies; the difierences in shape depending apparently on the density of
the fluid suspending them. In the same proportion as it becomes less
dense, they tend to assume the more perfectly spherical shape. They
have a uniform nebulous or grumous aspect ; distinct granules, more
or less numerous, are commonly seen in them ; and they appear more
darkly nebulous and more granular in the same proportion as the fluid
becomes more dense. Their usual diameter is from ig^^j^ to ^ j^^ of an
inch. Sometimes a distinct, circular, dark-edged nucleus may be seen
in the paler corpuscles ; and, more rarely, two or even three particles
like a divided nucleus.
When, as in the corpuscles B, water is added to pus, it usually pene-
trates the cells, expanding them, raising up a distinct fine cell-wall,
and separating or difi'using their contents. Sometimes the contents are
imiformly dispersed through the distended cell, which thus becomes
more lightly nebulous, or appears filled with a nearly clear substance
in which the minute particles vibrate with molecular movement, while
in or near the centre a dark-edged well-defined nucleus may appear.
12
170 SUPPURATION.
Sometimes, while the cell-wall is upraised, the whole contents of the
cell subside into a single ill-defined darkly nebulous mass, which re-
mains attached to part of the cell-wall, looking like a nucleus, but dif-
fering from a true nucleus in the characters just assigned, as well as in
the absence of the two or three shining particles like nucleoli. Lastly,
a few pus-corpuscles appear unchanged by the action of water : they
seem to be merely masses of soft colorless substance, having the shape
and appearance, but not the structure, of cells.
When dilute acetic acid is added to pus (as in Fig. o), it produces the
same effects as water, but more quickly, and with a more constant ap-
pearance of two, three, or four small bodies like nuclei. These bodies
are remarkable, though far from characteristic, features of pus-cells.
They are darkly edged, usually flattened, clear, and grouped, as if
formed by the division of a single nucleus : and commonly each of them
appears darkly shaded at its centre. When the acetic acid has been
too little diluted, these bodies alone may be at first seen : for the cell-
wall and the rest of its contents may be rendered so transparent as to
be scarcely visible.
Such are the pus-cells found in healthy suppurating wounds. The
liquor puris contains albumen, a compound called pyin, regarded by
Mulder as identical with tritoxide of protein, occasionally chondrin,
glutin and leucine, abundant fatty matter, and inorganic substances
similar to those dissolved in the liquor sanguinis.
Pus not distinguishable from that of granulating wounds is formed in
many other conditions ; as in inflamed serous and mucous cavities, and
in abscesses. In these relations it will be considered in the lectures on
Inflammation. But the histories of all cases of the formation of pus
concur, with that of suppurating wounds, to the conclusion that pus
may be regarded as a rudimental substance ill-developed or degenerated ;
as a substance essentially similar to the materials of granulations, or
of the lymph of inflammatory exudation, but which fails of being de-
veloped like them, or, after having been developed like them, to a cer-
tain stage, degenerates.
To illustrate this relation between the pus and the granulations of
healing wounds, I may state that the last figure was copied from sketches
that I made, at the same time, of some granulation-cells from the walls
of a sinus, and some pus-cells from a healthily granulating wound. I
chose those sources purposely, that I might be able to compare ill-de-
veloped granulation-cells with well-constructed pus-cells ; and a com-
parison of them showed that, whether as seen without addition, or as
changed by the action of water and acetic acid, they were not to be
distinguished from one another. Had I not seen the vessels in the tis-
sue that the granulation-cells formed, I might, in the first examination,
have almost thought I was deceived in thinking they were not pus-cells.
The six varieties of the appearances of the cells which are represented,
might have been taken from either source; so might some other varie-
SUPPURATION. 171
ties : but these may suffice to show the apparent identity of structure
between well-formed pus-cells and ill-developed or degenerate granula-
tion-cells, such as are found in the walls of sinuses and the like half-
morbid structures. I do not mean to say, generally, that granulation-cells
and pus-cells cannot be distinguished ; for between well-formed granu-
lation-cells, such as are found in healing wounds, and any particles that
are usually found in pus, certain distinctions are almost always manifest.
The pus-cells are darker, more and more darkly granular, more various
in size, and more various, not in shape, but in apparent structure, more
often containing numerous particles, like fatty molecules, more rarely
showing a nucleus when neither water nor acetic acid is added, and much
more commonly showing a tripartite or ill-formed nucleus under the
action of the acid. None, however, of these characters is indicative of
essential difference ; and between even the widest extremes there are all
possible gradations, till distinction is impossible ; so that when you
place, as I have often done, ill-developed or degenerate granulation-cells
on one side of the microscope-field, and pus-cells on the other, there is
not a form of corpuscle on the one which is not repeated on the other.
From this, one cannot but conclude that the cells of pus from wounds
are ill-developed or degenerate granulation-cells. Some of them may be
degenerate, t. €., they may have been, as granulation-cells, attached
for a time to the surface of the granulation-layer, and having lived their
time, may, in ordinary course, have been detached and shed, as epithe-
lial cells are from healthy surfaces. They may be thus detached after
more or less degeneration, and hence may result some of the modifica-
tions that they present. But some pus-cells, I imagine (at least in the
healing of wounds), may be ill-developed ; that is, imperfectly formed
of the granulation material, which, being exposed to the air, or being
too remote from the supply of blood, ciCnnot attain its due development,
and, in an imperfectly developed state, is soon cast off.
The many characters of imperfection or of degeneracy that pus-cells
show, accord with this view : such as the general imperfection of their
nuclei ; the frequent abundance of fatty-looking granules in them ; the
large quantity of fatty matter that analysis detects in pus ; and the
limitation of the cells to certain forms, beyond which they are never
found developed, though none of these forms is more highly organized
than that of the youngest or most rudimental granulation-cell.*
A further confirmation of the opinion that pus-cells are ill-developed
or degenerate granulation-cells, is furnished in the cases, to which I
shall hereafter refer, in which pus-cells are produced after, or together
with, inflammatory lymph-cells ; as in abscesses, inflamed membranes,
and the like. Now such lymph-cells are not distinguishable in apparent
stracture from granulation-cells, and, like these, they may show every
gradation of form to that of the pus-cell.
* Id a note to Lecture XVI, a description of the views held by many pathologists of the
fonnatioo of pus by the proliferation of the nuclei of the textures is given.
L
172 SUPPURATION.
But it is not only in the cells that we may trace this appearance of
the degeneracy or incomplete development of pus. It is equally shown
in the fluid part, or liquor puris, which, unlike the intercellular sub-
stance of granulations and inflammatory lymph, is incapable of organi-
zation, even when, by evaporation or partial absorption, it assumes the
solid form. The liquor puris answers, in its relations to the cells, to
the solid and organizable intercellular substance of granulations ; and
as undue liquidity is among the most decided marks of ill-formed pus,
so the abundance of the blastema, in proportion to the cells, is one of
the best signs that granulations are capable of quick development.
These considerations may suggest, in some cases, the imperfection of
the liquor puris ; and an observation, which any one may easily make,
seems to indicate that it may, in other cases, be the product of the
degeneration and liquefaction of the solid blastema, as the pus-cells are,
in the same cases, of the granulation or inflammatory lymph-cells im-
bedded in it. If the formation of abscesses be watched, one may see,
on one day, a large solid and inflamed swelling, firm and almost un-
yielding, giving no indication of containing any collection of fluid ; but,
next day, one may detect in the same swelling the signs of suppura-
tion ; the border may feel as firm as before ; but all the centre and the
surface may be occupied with an ounce or more of matter. And ob-
serve, this change from the solid to the liquid state may have ensued
without any increase of the swelling. Such an increase must have
occurred had the pus been secreted in a fluid state into the centre of
the solid mass : and the changes cannot, I think, be explained except
on the admission, that the inflammatory product, which was eflused and
infiltrated through the tissue in a solid form, has been liquefied : its
cells degenerating into pus-cells, its blastema into liquor puris.*
Can we assign any use or purpose to the process of suppuration ? In
the case of abscesses and acute inflammations we may discern no more
of purpose than in any other disease. But in the case of granulating
wounds, the use commonly assigned to pus, that it serves as a protection
to the granulations, is probably ascribed to it with reason. It does
this even in the fluid state ; but the devices of surgical treatment,
having regard to present comfort, rarely let us see how much better it
protects a wounded surface when, as in animals, it is allowed to dry
into a scab.
Let us now consider the case of a wound completely healed, and the
scar that occupies its place.
It is hard to describe in general terms the characters of scars, vary-
* Such a liquefaction is not that assumed in the older doctrines, which held that pus was
partly formed of the dissolved materials of the original tissues. The original tissues doubt-
less remain, unless partially absorbed: yet there appears to be thus much of liquefaction in
the formation of an abscess, that part of the inflammatory protluct, first formed as a soft
solid, degenerates and becomes tluid.
SCABS. 173
ing as they do in accordance with the peculiar positions, and forms, and
modes of healing of wounds. But two things may be constantly ob-
served in them : namely, their contraction, and the gradual perfecting
of their tissues.
A process of contraction is always associated with the development
of granulations. Mr. Hunter has minutely described it, and preserved
several specimens to illustrate it: among which are two stumps,* in
which its occurrence is proved by the small size of the scars in com-
parison with that of the granulating surfaces which existed before them.
This healing of stufeips, especially after circular amputations, will
always show the contraction of the granulations, even before the cica-
trix is formed ; for one sees the healthy skin drawn in and puckered
over the end of the stump, before any cuticle is formed on the granula-
tions, except perhaps on the very margin. And many injuries, but
especially burns, show the contraction of the scar continuing long after
the apparent healing is completed.
To what may we ascribe this contraction of both the granulations
and the scar ? It has been regarded as the result of some vital power
of contraction ; and possibly it may be so in some measure. Yet, on
the whole, it seems rather to be the necessary mechanical effect of the
changes of form and construction that the parts undergo. The same
change ensues in the organization of inflammatory products : as, e. g.^
in false membranes, indurations, thickenings of parts, and the like con-
sequences of the exudation and organization of lymph.
Now, in all these cases, the form of the cell, while elongating into a
fusiform body, is so changed that it will occupy less space. The whole
mass of the developing cells becomes more closely packed, and the tis-
sue that they form becomes much drier ; with this, also, there is much
diminution of vascularity. Thus, there results a considerable decrease
of bulk in the new tissue as it develops itself ; and this decrease, be-
ginning with the development of the granulation- cells, continues in the
scar, and, I think, suflSciently accounts for the contraction of both,
without referring to any vital power.
The force with which the contraction is accomplished is often enor-
mous. One sees its result in the horrible deformities that follow the
healing of severe burns. Deep scarred and seamed depressions, even
of the bones, may be produced by the contraction of granulations and
scars over them. The whole process shows the error of such expres-
sions as "filling up with granulations," commonly applied to deep
healing wounds, as if granulations increased in thickness till they at-
tained the level of the upper margins of deep hollows. The truth is,
that, even in the deepest open wounds, the granulation-layer is, as
usual^ from one to three lines thick ; and that, when such a wound
grows shallower in healing, it is not by the rising of the granulations,
* Nos. 28 and 29 in the Museum of the College.
I
174 SCABS.
but by the lowering of its margins. The granulations and the scars of
deep open wounds remain alike thin and depressed.
The improvement and perfecting of the tissue of the scar is, againy a
very slow process. It is often thought remarkable that nerves and
some of the higher tissues should require so long time for their repair ;
but scarcely less is necessary for the perfecting of a common scar. The
principal changes by which it is accomplished include the removal of
all the rudimental textures, the. formation of elastic tissue, the improve-
ment of the fibrous or fibro-cellular tissue, and of the new cuticle, till
they are almost exactly like those of natural formation ; and the gradual
loosening of the scar, so that it may move easily on the adjacent parts.
The scar also becomes paler and more shining than the surrounding
unaffected skin, for the numerous vessels, which the granulating surface
possessed, gradually disappear, and are, for the most part, converted
into fibrous cords.
All these changes are very slowly accomplished. One sees their
effects, it may be, only after the many years in which, as it is said, the
scars of childhood gradually wear out; i. e., in which the new-formed
tissues gradually acquire the exact similitude of the old ones. Thus,
the remains of the rudimental connective tissue, imperfectly developed,
may be found in apparently healthy scars of ten months' duration.
After second operations, in which the scar of some former wound was
removed, I have still found imperfectly developed granulation- cells in
the tissue of the scar. Elastic tissue, also, I think, is not commonly
formed in the first construction of a scar, but appears in it sometimes
as much as twelve months after its first formation, and then gives it the
common structure of the mixed white fibrous and elastic tissues which
exist in the cutis.
But, an occurrence which may appear more singular than this slow
perfecting of the tissues, is, in all good scars, as they are called, that
gradual loosening of the tissue which at first unites the scar to all the
adjacent parts. Thus, in such a wound as is made for tying a deep ar-
tery, or in lithotomy, at first the new tissue, the tissue of the scar, ex-
tends down to the bottom of the wound, equally dense in all parts, and
fastening the skin to the parts at the very deepest portion of the wound.
But after a time this clears up. The tissue of the scar in the skin be-
comes more compact and more elastic ; but that beneath it becomes
looser and more like natural connective tissue, and the morbid adhe-
sions of one part to another are freed. So, after injuries or diseases,
followed by scars about joints, the stiffness depending on the adhesion
of the scar to the deeper tissues gradually decreases : and so, in like
manner, the scars of burns often become gradually and of themselves
more pliant, and the parts which they held become more freely mova-
ble, though sometimes scarcely seeming to change for a year after the
first healing of the injury.
REPAIR OF FRACTURES. 175
Now, in all this gradual return of tissues to the healthy state, we
may trace, I think, a visible illustration of the recovery from the minute
changes of disease. In all there is a gradual approach of the new par-
ticles that are successively produced, to a nearer conformity with the
specific character of the parts they should replace, till repair becomes
almost reproduction. And how, let me ask, can all this be reconciled
with any theory of assimilation? How can assimilation alter the cha-
racters of a scar ? How make one part of it assume one character, and
another part a character quite different, till, at length, that which
looked homogeneous, as a mass of new-formed tissue, acquires, in sepa-
rate parts, the characters of the several tissues in whose place it lies,
and whose office it is destined, though still defectively, to discharge ?
LECTURE XL
THE REPAIR OF FRACTURES.
The necessity, which I have felt in the preceding lectures, of describ-
ing the healing process as it is observed in a few typical examples, is
increased, when I come to the consideration of the repair of fractures.
A volume would not suffice for all that should be said of it ; for there
are no examples of the reparative process which present so many fea-
tures of interest as this does, whether we consider its practical impor-
tance, or the wide field which it offers alike for the science and for the
art of surgery, or the abundant illustrations of the general principles of
recovery from injury which are present in every stage of the process,
or the perfect evidences of design which it displays, of design that
seems unlimited in the variety and point with which it is adapted to all
the possible diversities of accident. To consider the repair of fractures
completely, in any of these views, would be far beyond my purpose, and
farther beyond my ability. I shall therefore limit myself almost en-
tirely to an account of the repair of the simple fractures of long bones.
What is true of this will be so nearly true of the repairs of other frac-
tures, that a few words may suffice in reference to the chief modifications
of the process in them. Moreover, I shall in general describe only what
occurs in the adult human subject.
The injury inflicted in the fracture of a long bone is rarely limited to
the bone. The two or more fragments, driven in opposite directions,
penetrate the adjacent tissues, wounding and bruising them, and giving
rise to bleeding of various amount. Provided all these injuries are
subcutaneous, and the air has no access to the damaged parts, their re-
pair is perfectly, though slowly, effected. It is not unfrequent, in
recent fractures, to find portions of muscle or other soft parts com-
176 REPAIR OP FRACTURBS.
pletely crushed by the bones, or even, in minute fragments, inclosed
in the reparative material or the inflammatory exudations ; and yet,
when similar fractures are examined a year or more after their occur-
rence, the tissues round the bone appear quite normal in their struc-
ture, however disturbed they may be in their relations.
The periosteum is rarely much damaged in fractures of long bones.
It is seldom stripped off the broken ends. Commonly, it is cleanly
rent across at the same level as the bone is broken, and maintains its
close union, having only its fibres somewhat frayed or pulled from their
natural direction. Sometimes, indeed, it remains entire, even in exten-
sive fractures ; and in this case, thickening, it contributes to the security
of the repair of the injury.
The extravasation of blood about fractures is not only uncertain in
amount, but unequal in the several tissues. Its abundance in the sub-
cutaneous tissue is often so remarkable, ds to be among the useful signs
for diagnosis, in cases of doubtful fracture near joints; but in the
deeper soft tissues less blood is shed ; and, commonly, in the periosteum,
near the broken ends of the bone, only a few spots of blood are seen.
I have already spoken (p. 137) of the manner in which the extra vasated
blood is disposed of; and since it rarely appears to take part in the
reparative process, I shall make no further mention of it.
Some days elapse, after a fracture, before any clear marks of a re-
parative process can be found. An early consequence of the injury
appears to be the exudation of a small quantity of inflammatory lymph;
so that the fibro-cellular tissue in and near the seat of injury appears
more succulent than is natural, being infiltrated with a serous-looking
fluid, in which are cells like those of granulations or lymph.
In bad cases, this exudation may increase, and add to the swelling
that is often seen to augment in the second or some later day ; but, in
better instances of repair, and when the parts, even though much in-
jured, are kept at rest, I think the inflammatory exudation usually
ceases after the second or third day, and that, then, some days pass before
the proper reparative material is produced.* The state of the injured
parts during this period of calm, or of incubation, is probably like that
observed in wounds of soft parts (p. 152). Its duration is uncertain,
but, I think, in the adult, is rarely less than one week or more than two.
In this long period of inaction we find the first contrast between the
repairs of fractures in man, and in the animals that have been used for
experimental inquiry into the process, as dogs, rabbits, pigeons, and
others. In any of these, an abundant reparative material will be pro-
duced, and organized into cartilage or bone, in a time little longer than
elapses before the first commencement of the process in a man.t We
* More concerning this inflammatory exudation will be related in the account of the re-
pair of tendons, in the next lecture.
t See Nos. 418, 419, 4v>0, in the Museum of tlie College ; and Series iii, Nos. 69, 70, 71, &c.,
in that of St. Bartholomew's.
REPAIR OP FRACTURES. 177
cannot, therefore, from the rapidity of repair in any lower animals, form
any just calculation of its rate of progress in ourselves.
The proper reparative process, commencing after this period of rest,
may usually be divided into two chief parts ; namely, the process of
uniting the fragments, and that of shaping or modelling them and their
combining substance. The uniting and the modelling parts of the process
are so diflferent in nature and in time, that they may well be considered
separately. They are comparable with the forming and the subsequent
perfecting of the scars of wounded soft parts ; and in the union of frac-
tures, even more evidently than in any other instance of repair, we may
note how safety is first provided for, then symmetry; how the welfare
of the individual is first secured, and then the conformity of the repaired
part to the typical or specific form ; for the modelling scarcely begins
before the uniting is completed.
The union of fractures is commonly effected by the organization of
new material connecting the fragments. Sometimes, indeed, immediate
union occurs. When portions of bone are placed and held in exact
apposition, they may be united without any new material being formed
for their connection ; a continuity of tissues and of bloodvessels being
restored, as in the cases of healing by immediate union of soft parts.
But this is rare, and has not yet been sufficiently studied.
The material deposited for the more usual method of repair of simple
fractures, — the callus, as it is called, when it has become firm or hard, —
is, I think, in the first instance, not visibly different from the material
formed for the repair of other subcutaneous injuries. Its peculiarity is
shown in the direction and end of its development ; and, in this respect,
the repair of fractures supplies an extreme case of the variety of ways
through which the same end of development may be attained.
In its first production, the reparative material is a structureless or
dimly shaded, or granular substance, like fibrine ; or, perhaps at a later
period, it is ruddy, elastic, moderately firm and succulent, like firm
granulation-substance. Of the manner in which it is placed, in the
space and in the tissues around or between the fragments to be connected,
I will speak presently. At first, it has none of the firmness belonging
to the "callus:** this, however, it soon attains, as it makes progress
towards being transformed into bone. Its ossification, as I have said,
may be accomplished through several transitional forms of tissue, which
might be distinguished as so many varieties of callus, if the term be
worth retaining. It may become, before ossifying, either fibrous or
cartilaginous, or may assume a structure intermediate between these ;
and, in either of these cases, ossification may ensue when the previous
tissue is yet in a rudimental state, or may be delayed till the complete
fibrous or cartilaginous structure is first achieved.
I cannot tell the conditions which will determine, in each case, the
route of development towards bone that the reparative material will
take ; nor in what measure the differences that may be observed are to
178 RBPAIR OF FRACTURES.
be ascribed to the seat or nature of the injury, or to the condition of the
patient. All these things have yet to be determined ; and I belieye
that years of patient and well-directed investigation will be requisite for
them. I can do little more than point out the modes in which the ossi-
fication may be accomplished.
And, first, it may be accomplished through perfect fibrous tissue.
Thus I found it in a case of fracture of the lower part of the femur after
six weeks, and in a fracture of the radius after about nine weeks ; thus,
too, I think, whatever new bone is formed after fractures of the skull
is developed ; and thus one may find, in the neighborhood of fractures
and other injuries of bone, ossifications of interosseous fibrous mem-
branes, and of the tissue of the periosteum, or just external to it.'*'
But, secondly, the new bone may be formed by ossification of the
fibrous tissue in a rudimcntal state. And this rudimental state may be
that of either nucleated cells or nucleated blastema. Through nu-
cleated cells and the intercellular substance between them, as the
embryo forms of fibrous tissue, bone is formed when granulations or in-
flammatory exudations ossify. The process may be often seen in the
union of compound fractures, or of simple ones when much inflamma-
tion has been excited. But, best of all, though here only for illustra-
tion of what may occur in fractures, the ossification of nucleated cells,
with their intercellular substance, in granulations, may be observed,
when bone is formed in the mushroom-shaped mass of granulations that
is protruded through the medullary canal of a bone sawn across in an
amputation. t In all these cases there appears to be a direct transfor-
mation into bone, without the intervention of either cartilage or perfect
fibrous tissue.
The ossification of nucleated blastema, such as I have described as a
rudimental form of fibrous tissue, may also be seen in simple fractures ;
and my impression is, that it is an ordinary mode of ossification in
simple fractures of adult long bones that unite well and quickly. In
such a case, in a fracture of the tibia of five weeks date, I found, in
long-continued examinations, that the bone is formed without any inter-
mediate state of cartilage ; a finely and very closely granular osseous
deposit taking place in the blastema, and gradually accumulating so as
to form the delicate yet dense lamellae of fine cancellous tissue. The
nuclei of the blastema appeared to be inclosed in the new-forming bone,
and I thought I could trace that they became the bone-corpuscles ; but
I could not be sure of this. Yet the belief is justified by the opinion
now entertained by many physiologists that, in the normal development
of bone out of fibrous membrane, the cells of the connective tissues
become the corpuscles of the bone.
* The thill plate of bone which closes in the exposed medullary canal of the end of a
fractured long bone, where one fragment overlaps another, will usually, I think, present a
good example of ossification of fibrous tissue.
t College Museum, Nos. 552, 553.
BBPAIR OP FRACTURBS. 179
Thus, the new material produced for the repair of fractures may be
ossified throujich an intermediate fibrous stage. In other instances it
may pass through a cartilaginous stage. In animals, perfect cartilage,
with its characteristic homogeneous intercellular substance, its cells,
and all the characters of pure foetal cartilage, may be produced.
Through the ossification of such cartilage, Miescher* and Voetsch,t
and others, describe the repair of fractures as accomplished in dogs,
pigeons, and other animals ; and A. Wagner;]; has noticed, in his ex-
periments on the resection of bones in rabbits and pigeons, a process
of repair of a closely corresponding nature. I have not yet found the
▼ery same process in the human subject ; but I should think it would
occur in favorable instances of simple fracture in children. In youths
and adults, I have found only varieties of fibrous cartilage ; and these
have presented numerous gradations from the fibrous towards the per-
fect cartilaginous structure. In diiferent specimens, or sometimes even
in different parts of the same, the reparative material has displayed, in
one, fibrous tissue, with a few imbedded corpuscles, like the large nearly
round nuclei of cartilage-cells ; in another, a less appearance of fibrous
structure, with more abundant nucleated cells, having all the characters
of true cartilage-cells ; and in a third, a yet more nearly perfect carti-
lage.§
Through any of these structures the reparative new bone may be
formed. It may be formed, first, where the reparative material is in
eontact with the old bone, and thence extending it may seem as if it
grew from the old bone ; or it may be formed in the new materia], in
detached centres of ossification, from which it may extend through the
intervening tissues, and connect itself with the old bone (see Figs.- 21
uid 28).
The new bone, through whatever mode it is formed, appears to acquire
quickly its proper microscopic characters. Its corpuscles or lacunae, being
first of simple round or oval shape, and then becoming jagged at their
edges, subsequently acquire their canals, which appear to be gradually
hollowed out in the preformed bone, as minute channels communicating
with one or more of the lacunae. The laminated canals for bloodvessels
are later formed. At first, all the new bone forms a minutely cancel-
lous structure, which is light, spongy, soft, and succulent, with a red-
dish juice rather than marrow, and is altogether like foetal bones in
* De Inflammatione Ossium, 1836. I Die Heilung der KnochenbrQcbe, 1847.
{ Eaaay traoslated for the New Syd. Soc., 1859. The statements in the text are also con-
finned generally by Wedl in his Pathological Histology.
{ 1 do not describe the minute methods of ossification occurring in the callus, or repara*
tire material; for my opportunities of studying it in man have been too few for me to con-
clude from : and, although I have seen nothing opposed to the belief that the normal methods
of ostiflcation are imitated, yet the process seems capable of so many modifications that I
think it would not be safe to adapt, unconditionally, to the case of the reparative material in
man, such cooclasiona as are drawn from the normal ossification of his skeleton, or from the
Msification of the reparatlTe material in lower animals.
180 REPAIR OF FRACTURES.
their first construction. But this gradually assimilates itself to the
structure of the bones that it repairs ; its outer portions assuming a
compact laminated structure, and its inner or central portions acquiring
wider cancellous spaces, and a more perfect medulla. It acquires, also,
a defined periosteum, at first firm, thin, and distinctly lamellar, and
gradually assuming toughness and compactness. But, in regard to many
of these later changes in the bonds of union of fractures, there are so
many varieties in adaptation to the peculiarities of the cases, that no
general account of them can be rendered.*
A subject of chief interest in the repair of fractures is the position
of the reparative material, and in relation to this we find a greater dif-
ference than any yet mentioned between the processes traced respec-
tively in man and in the animals submitted to experiments.
There are two principal methods according to which the reparative
material, or callus, may be placed. In one, the broken ends or smaller
fragments of the bone are completely inclosed in the new material ; they
are ensheathed and held together by it, as two portions of a rod might
be by a ferrule or ring equally fastened around them both. In such a
case, illustrated by Fig. 21, the new material, surrounding the fracture,
has been usually called "provisional callus," or "external callus:" but
the term " ensheathing callus " will, I think, be more explanatory. In
the other method (as in Figs. 22 and 23), the new material is placed only
between those parts of the broken bone whose surfaces are apposed ;
between these it is inlaid, filling the space that else would exist between
them, or the angle at which one fragment overhangs another, and
uniting them by being fixed to both. Reparative material thus placed
may be called "intermediate callus.*' In either method (as in Figs,
21 and 22), there is usually some reparative material deposited in and
near the broken medullary tissue ; and this may be still named " inte-
rior callus."
The method of repair with an ensheathing or provisional callus is
rarely observed in man, but appears to be frequent in fractures of long
bones in animals. f From these it has been admirably described by
* Many very excellent observations have been made in France, of late years, by Flonrens,
Oilier, Deinarquay, and others, illustrating the importance of the periosteum in the formation
of nevtr bone. Their experiments have shown not only that large portions of the shaft of a
bone may be reproduced if the periosteum is not removed, but that bone may be made
to grow in a part not customary, by transplantation of a portion of periosteum. By these
observations, the principles of DiiHamel as to the reproduction of bone have been extended,
and the facts long ago proved by Syme have been corroborated by more remarkable in-
stances. A somewhat ditierent interpretation of the regenerative power of the periosteum,
has been put forward by Prof Goodsir. (Anat. and Path. Observ.) He argues that it is
impossible to separate tlie periosteum in living animals without detaching minute shreds of
bone along with it, and that it is from these shreds, rather than from the periosteum itself,
that the regenerative process is set up.
f Even in animals it is not constant. To obtain what would be called good specimens
of provisional callus, the injuries must be inflicted upon young animals, and among these I
cannot but suspect that particular instances have been selected for description ; those in
RBPAIB OF FBACTCEE8.
181
rig. 21.
Dupuytreo and others. The chief features of the process are as fol-
lows (omitting dates, which have not been ascertained in man, and can-
not well be calculated for him) :
In the simplest case, when the fragments (as represented in this dog's ■
tibia : Fig. 21) lie nearly in apposition, and nearly correspond, the re-
parative material accumulates at once around and within them, and in
any interspaces that may be left between them. That around them, that
is, the ensheathing callus, forms most quickly
and in greater abundance, and lies chiefly or
solely between the wall of the bone and the peri-
osteum, which is thus lifted up from the wall, the
bloodvessels that passed from it into the bone
now passing to their destinations through the
callus. The distance from the broken ends to
which the callus extends up each fragment is
uncertain ; in the long bones of dogs, and the
ribs of men, it is usually about half an inch.
The thickness of the callus is greatest at a little
distance from the plane of the fracture : exactly
in that plane it is usually less thick than either
above or below ; so that, even when it is ossified,
it is often marked with a slight annular con-
striction.
The interior callus fills up the spaces in the
cancellous tissue, extending in the medullary
canal of each Fragment to a distance somewhat
short of that to which the ensheathing callus
reaches. At the end of each fragment there is
Dsually an abrupt contrast between the firm re-
parative material that forms this interior callus,
and a softer substance, like that of granulations,
which remains between the fragments even till
Ihe callus without and within is quite ossified.
As the section drawn in Fig. 21 shows, the re-
parative material is abundant and well developed
both around and within the fragments : but between them, t. e. in the
plane of the fracture, it is sparingly formed and soft, so that the frag-
ments, if the ensheathing callus were removed, would be no longer held
together ; they are, in fact, combined long before they are united.
The ossification of the ensheathing callus is accomplished chiefiy or
which lencallui wai rormed bHriiitc been put a^
id miib, Ihey iraj have diaplajred Ibe more nali
thaMiueamof the College, Nos. 418 to 436 ; and
71,96,81,83,9-3, 106. Pig. 21 ia drawn frnni N
naliofu of Trnctuied long bones recently united ii
eas imperfect instances of lepair, though,
I process. Such good specimens are, in
Ihal of St. Batthoiomews, Ser. iii, fi9, 70,
Ml. It is very desirable lo obtain eiami-
-oung children ; fbr il is probable that
ixperimenis oi
No
182 REPAIR OF FRACTURE6.
solely by outgrowth of bone from the fragments on which it is placed.
Here, also, the same method of progress is observed, in that the for-
mation of new bone extends gradually towards that part of the callus
which exactly corresponds with the plane of the fracture. This part of
the callus is last ossified; but, at length, its ossification being complete,
the fragments are combined by and within a sheath or ferrule of new
bone. The interior callus, ossifying at about the same time, consoli-
dates the cancellous tissue of the fragments, and, at a later period,
unites them. The walls remain still longer disunited. The ossified
callus is, indeed, sufficient to render the bone fit for its office, but it
retains the nearly cancellous tissue of new bone, and it is still only
provisional : for when the walls of the fragments are themselves united,
and their continuity is restored, all, or a part, of the external callus is
removed, and the cancellous tissue loses its solidity by the removal of
the internal callus.
Such is the process of repair with an ensheathing callus. It is, as
I have said, usual in animals ; but in man I have never seen its occur-
rence as a natural process in any bones but the ribs. In these it may
be traced as perfectly as I have described it from the instances of
repaired fractures of long bones in the rabbit and dog. Sometimes,
indeed, a similar process occurs in other human bones. I have seen it
in the clavicle and humerus ;* but in both these cases the more proper
mode of repair had been disturbed by constant movement of the parts,
and in the humerus the process had manifest signs of exaggeration
and disease.
The normal mode of repair in the fractures of human bones is that
which is accomplished by " intermediate callus.*' The principal features
of difference between it and that just described are, (1) that the repara-
tive material or callus is placed chiefly or only between the fragments,
not around them ; (2) that, when ossified, it is not a provisional, but a
permanent, bond of union for them ; (3) that the part of it which is
external to the wall of the bone is not exclusively, or even as if with
preference, placed between the bone and the periosteum, but, rather,
in the tissue of the periosteum, or indifferently either in it, beneath it,
or external to it.
When the fragments are placed in close apposition and correspon-
dence, they may, I believe, be joined by immediate union ; but if this do
not happen, a thin layer of reparative material is deposited between
them ; it does not, in any direction, exceed the extent of the fracture ;
neither does it, in more than a trivial degree, occupy the medullary
canal ; but, being inlaid between the fragments, and there ossifying, it
* Museum of St. Bartholomew's, Ser. iii, 92, 65, and C6. The clavicle was broken twelve
weeks before death ; but the fracture was not detected, and the fragments were allowed to
ipove unrestrained. The humerus was taken from a man who died some weeks after the
fracture, and whose arm had, for several days after the injury, been the seat of severe
spasms. See Mr Stanley's ^' Illustrations of Diseases of Bones,'' pi. xxiii, fig. 3.
BEPAIR OP FRACTURES.
183
restores their continnity. The process may be compared with that of
nnioD by primary adhesion.
When, as more commonly happens, the fragments, though closely
apposed, do not exactly correspond, but, at certain parts, project more
or less one beyond the other, the reparative material is, as ia the for-
mer esse, inlaid between them, and to a slight extent, in the medullary
canal ; but it is also, in larger quantity, placed in the angles at which
the fragments overhang one another. Its position is, in these cases,
well shown in the specimens drawn in the 22d and 28d figures. In
Pig. 22.
Fig. 28.
tlie fractured radius* (Fig. 22) the carpal portion, laterally displaced,
projects beyond the radial margin of the upper and impacted portion ;
tnd the angle between them is exactly filled, without being surpassed,
)>; a wedge-shaped mass of reparative material. So, but less perfectly,
» the angle on the ulnar side. In the fractured femnrf (Fig. 23), with
great displacement of the fragments, the same rule is observed ; the
interspace between the fragments, and parts of the angles at which the
MK projects beyond the other, are filled with partially ossified repara-
" MnwDin orSL Buiholomaw'f, Ser. iii, No. 94.
f The Kune Huaeiim, Ser. iii, No. 103.
184 REPAIR OF FRACTURES.
tive material. In neither case is there an ensheathing callus ; in
neither is any reparative material placed on that aspect of the one
fragment which is turned from the other.
Lastly, when the fragments neither correspond nor are apposed,
when one completely projects beyond or overlaps another, and when, it
may be, a wide interval exists between them, still the reparative ma-
terial is only placed between them. It just fills the interval ; it does
not even cover the ends of the fragments, or fill any part of the medul-
lary canal : much less does it inclose both the ends of the mutually
averted surfaces, as the provisional callus would in a similar fracture in
a dog or a rabbit ; it passes, bridge-like, from one fragment to the
other, and thus, when ossified, combines them. Thus it appears in the
fractured femur, part of which is represented in Fig. 24.*
The three instances which I have cited, of different relative positions
of the fragments, may suffice as examples of classes in which nearly all
simple fractures of long bones might be described. But, whether the
displacement were like either of these, or of any other kind, I have
seen no examples (other than the exceptions already mentioned) in
which the reparative material has been placed according to a different
method.f It is always an intermediate bond of union ; it is inlaid be-
tween the fragments ; and when formed in largest quantity, is only
enough to smooth the chief irregularities, and to fill up the interspaces
and angles between them. And, regarding the particular position
which it may in each case occupy, I do not know that it can be more
exactly described, than by saying, that it is deposited where it is most
wanted for the strengthening of the bone ; so that, wherever would be
the weak part, if unhealed, there is the new material placed, in quantity
as well as in position just adapted to the exigencies of the case, and
restoring, as much as may be, the original condition and capacities of
the bone.
If, now, it be inquired why this difference should exist in the cor-
responding processes in man and other animals, I believe it must be
ascribed principally to two causes, namely, the quietude in which frac-
* Museum of St. Bartholomew's Hospital, Ser. iii, No. 98.
f I exhibited at this lecture all the specimens of fractures examined within six months
of ttie injury that are contained in the Museums of the College and St. Bartholomew's ; and
they all, with the exceptions already mentioned, exemplified this account of the repair by
intermediate callus, and of the absence of provisional or ensheathing callus. Tliey included
a radius, four weeks after the fracture; anotlier, four or five weeks; a tibia, five weeks; a
femur, six weeks; another of the same date; a third of about eight or nine weeks; a radius,
of somewhat later date; a tibia, eight weeks; a fibula, eleven weeks; a tibia, twelve
weeks; a tibia, sixteen weeks after the injury; and many others of various but unknown
dates, all in process of apparently natural repair. Since the lecture was given, the descrip-
tion has been confirmed by many examinations by myself and others. My conclusions
respecting the absence of ensheathing callus in the ordinary repair of fractures, are fully
confirmed by the observations of Dr. H. Hamilton, which were conducted at the same time
as mine, and led him, independently, to the same conclusion. See his Essay in the BuffaUt
Mtdical Journal for February, 1853.
REPAIR OF FRACTURES. 185
tures in oar bones are maintained, and the naturally greater tendency to
the production of new bone which animals always manifest. Even in-
dependently of surgery, in the case of fractures of the lower extremity,
the human mode of progression almost compels a patient to take rest :
and in fractures of the upper extremity, the circumstances of human
life and society permit him to do so far more than other animals can.
The whole process of repair is, therefore, more quietly conducted ; and,
as we may say, there is comparatively little need of the strength which
the formation of provisional callus would give a broken limb.
The exceptions to the rule, of difference in the repair of human bones
and those of animals, confirm it as thus explained ; for they are found
in the ribs, which are certainly never kept at rest during all the time
necessary for repair after fracture, and in bones of which, from various
causes, the repose of the fragments has been disturbed, or which have
been the seats of disease, with inflammatory deposit, during or sub-
sequent to the reparative process.
The comparative restlessness of animals is, however, I think, not
alone sufficient to account for all the difference in the processes. The
remainder may be ascribed to their greater tendency, in all circum-
stances, to the formation of new bone. Not in fractures alone, but in
necrosis this is shown. It is very rarely that such quantities of new
bone are formed in even children, as are commonly produced after
necrosis of the shafts of bones in dogs or other animals ; nor is there
in the human subject any such filling up of the cavities from which
superficial sequestra have been separated, as the experiments of Mr.
Hunter showed, after such exfoliations from the metatarsal bones of
asses.*
It remains, now, that I should describe the later part of the repair of
fractures, — that which consists in the shaping or modelling of the frag-
ments and of their bond of union.
Omitting the removal of the provisional callus, where such a one has
been formed, this modelling is best observed when there has been much
displacement of the fragments. In these cases, the chief things to be
accomplished are, 1st, the removal of sharp projecting points and edges
from the fragments ; 2dly, the closing or covering of the exposed ends
of the medullary tissue ; 3dly, the forming a compact external wall,
wd cancellous interior, for the reparative new bone ; and lastly, the
making these continuous with the walls and cancellous tissue of the
fragments.
* MuBeum of the Ck>llege, Nos. 64 L to 653.
The deDial of the formation of an ensheathing callus in the repair of fractures is some-
times met by the statement that such a callus can be often felt during life. The deception
•
upiodnced either by thickening and induration of the soft parts around the fracture; or by
^ two overlapping ends of the fragments being grasped at once ; or, much more rarely,
W new bone aceumnlated about the fragments in consequence of inflammation.
13
186
REPAIB OF FBACTCRB8.
Pig. 24.
The first of these is effected by the abaorption of the offending points
and angles ; and an observation sent to me by Mr. Delagarde tells mnoh
of the process : " A patient in the Exeter Hospital had a bad com-
minuted fractnre of the leg, and a long spike of the tibia, inclndmg
part of its spine, could not be reduced to its
exact level, but continued sensibly elevated,
though in its due direction. At the end of
five weeks (union having taken place) the
end of the spike began to soften ; at six, it
was quite soft and flexible, like a thin carti-
lage ; at the conclusion of the seventh week
it was blunt and shrunken. Six months
later, the cartilsiginous tip hod disappeared,
and the spike was rounded off."
I have since, in a similar case, seen the
same process repeated. Both cases seem to
show that the absorption of the bone is ac-
complished, as Mr. Hunter described it in
cases of necrosis, by removing first the
earthy matter, and then the softened re-
mains of animal substance.
The closing or covering in of the parts of
the broken medullary tube, which are ex-
posed in fractures with much displacement,
is slowly accomplished by the formation of a
thin layer of compact bone, like that which
covers the cancellous tissue at the articular
ends of bones. It is well shown in the ori-
ginal of the 24th figure.* In a fracture of
the femur, after six weeks, I have seen the
exposed medullary tube covered in with a
thin fibrous membrane, tense like a drum*
head, new-formed, and continuous with the
periosteum. The permanent closure appears
to be effected by the ossification of such a membrane ; and the new bone
becomes smoothly continuous with the rounded and thinned broken mar-
gins of the walls of the old bone. So arc the ends of stumps covered
in ; and neither in these nor in fractures have I seen new bone extending
into the medullary canal, as if formed by the ossification of an internal
callus.
The same sketch shows the nearly completed formation of distinct
walls and medullary tissue in the bridge of new bone connecting the
two fragments of the femur. At an earlier period we may be sure that
all this new bone was soft and cancellous ; it has now acquired the tes-
* From Ibe Museum of Si, Banholomew's, Ser. iii, No. SB.
REPAIR OF FRACTURES. 187
tures proper to the bone which it repairs, and, as if to complete its
conformity with the structures among which it was thus, by accident,
introduced, the process was begun by which the new and the old com-
pact and medullary tissues would become respectively continuous. Al-
ready those parts of the walls of the shaft that intervene like partitions,
separating the new from the old medullary tissues, are thin, uneven on
their surfaces, and in their interior half-cancellous. At some later
time they would, probably, have been reduced to mere cancellous tissue,
and the repair of the fracture would have been completed, crookedly
indeed, but with unbroken continuity of tissue.
To adapt the foregoing account to the case of compound fractures, it
is, I believe, only necessary (so far at least as the normal process of
repair is concerned) to say that the reparative material is more mingled
with products of inflammation ; that that part of it which is formed
within reach of the air, or in a suppurating cavity, is developed to bone
through the medium of granulations, like those formed in open wounds
of soft parts ; and that the whole process of repair is, generally, slower,
less secure, and more disturbed by morbid growths of bone, and other
effects of what has been named " ossific inflammation."
The data, at present collected, concerning the times in which the
several parts of the reparative process are usually completed after frac-
tures of adult human bones, are not sufficient for more than a general
and approximate estimate. They may be thus generally reckoned.
To the second or third day after the injury, inflammatory exudation in
and about the parts ; thence to the eighth or tenth, seeming inaction,
with subsidence of inflammation ; thence to about the twentieth, pro-
duction of the reparative material, and its gradual development to its
fibrous or cartilaginous condition; thenceforward its gradual ossifica-
tion, a part of the process which is, however, most variable in both its
time of commencement and its rate of progress, and, which is, probably,
rarely completed before the ninth or tenth week, although the limb may
have long previously recovered its fitness foi: support or other use.
From this time the rate of change is so uncertain, that it is impossible
to assign the average time within which the perfection of the repair is,
if ever, accomplished.
The consequences of failure in the process of repair may be illus-
trated by what I have described as its normal course. In a large part
of the cases of ununited fracture the fragments are connected by fibrous
or fibro-cartilaginous tissue, inlaid between them. Such is the defec-
tive union of most cases of fracture of the neck of the femur within
the capsule, and of the olecranon and the patella when their fragments
are not held close ; and such a defect may occur in any long bone. It
is an example of arrested development of the reparative material ; and
may be, in this respect, compared with the condition of granulations
188 REPAIR OF FRAGTURBS.
whose cells persist in their rudimental form. Every other part of the
process may be complete ; but this part fails, and the fragments are
combined by a yielding, pliant, and almost useless bond.
In other cases, the failure seems to occur earlier. No reparative
material is formed, and the fragments remain quite disunited. This
may be the result of accidental hindrances of the normal reparative
process: but it sometimes appears like a simple defect of formative
power ; a defect which, I believe, cannot be explained, and which seems
the more remarkable when we observe the many changes which may,
at a later time, be eflFected, as if to diminish the evil of the want of
union. Thus, commonly, the ends of bones thus disunited become
covered with a thin layer of fibrous tissue, polished as if with a cover-
ing of epithelium, and as smooth as an articular surface : similar smooth
linings form in the cavities that inclose them ; the tissues immediately
around them become condensed and fibrous ; and thus, at length, the
ends of the fragments are brought to the imitation of a joint, in which
they may move without mutual injury. Or, else, in the place of such
a false joint, the end of each fragment has a kind of bursal sac formed
on it, protecting the adjacent parts from injury in its movements. Bat,
much as may be thus accomplished, new bone is not spontaneously pro-
duced. As the result of disease, it may be formed ; and in this case it
is often formed uselessly, and without evident design, in heaps or no-
dules about the ends of the fragments ; yet it is of such disease that
surgery may often make happy use when it can excite inflammation of
the fragments, and so hold them close that the new bone may grow be-
tween or around them, and fasten itself to both.*
* It will diminish the defects of the foregoing description of the repair of fractures, which
I have drawn almost entirely from my own observations, if I subjoin a list of the works es*
pecially or chiefly devoted to this subject, in which the reader may find the best help to a
larger knowledge of the subject.
Dupuytren : Expos^ de la Doctrine de M. Dupuytren sur le Cal, par Sanson. In Jour.
Univ. des Sciences M6(iicales, t. xx.
Breschet : Recherches .... sur la Formation du Cal ; Thfese. Paris, 1819.
Howship: On the Union of Fractured Bones. Med. Chir. Trans, vol. ix.
Miescher: De Inflammatione Ossium eorumque Anatome. Berlin, 1836.
Flourens: Sur le Developpement des Os et des Dents. Paris, 1842.
Lebert: Sur la Formation du Cal. In his Physiologic Pathologique, t.ii, Paris, 1845.
Voetsch : Die Heilung der Knochenbrilche. Heidelberg, 1847.
Stanley : Illustrations of the Effects of Disease and Injury of the Bones, p. 27. 1849.
Malgaigne : Traite des Fractures et des Luxations, t. i. Paris, 1847.
Dusseau : Onderzoek van Het Beenweefsel en van Verbeeningen in zachte Deelen. Am-
sterdam, 1850.
Dusseau : De Callasvornening en de gessezing van Beenbrenking, in the Nederlandtek
Weekblad^ 1851. From an extrnct in the Nederlandsch Lancet^ Mai, 1852. I judge
that his account confirms, in all essential particulars, what I have written.
Oilier: On the Artificial Production of Bone. Brown-Sdquard's Journ. de Phys., Jan.
1859.
£. Gurit : Handbuch der Lehre v. d. KnochenbrQchen. Frankfort, 1860.
HEALING OF CARTILAGE. 189
LECTURE XIL ♦
HEALING OF INJURIES IN VARIOUS TISSUES.
This last lecture on the process of repair I propose to devote to the
consideration of the modes of healing of several different tissues ; modes
which, although they be all consistent with what has been said of the
general rules and methods of the healing process, yet present each some
peculiarity that seems worthy of observation.
And first (though it matters little which I begin with), of the healing
of wounds and other injuries of cartilage.
There are, I believe, no instances in which a lost portion of cartilage
has been restored, or a wounded portion repaired, with new and well-
formed permanent cartilage, in the human subject. When a fracture
extends into a joint, one may observe that the articular cartilage
remains for a long time unchanged, or else has its broken edges a little
softened and rounded oif. In one case, I saw no other change than
this in six weeks : but at a later period the gap is filled with a tough
fibrous tissue ; or rather, the gap becomes somewhat wider and shal-
lower, and the space thus formed is so filled up.
The excellent researches of Dr. Redfern* have ascertained the method
of this process in incised wounds of the articular cartilages of dogs.
As showing the slowness of the repair, he found in one instance, in
which he made three incisions into the cartilage of a patella, and two
into that of the trochlear surface of the femur, that no union had taken
place in twenty-nine weeks. No unusual cause for the want of union
had been apparent, yet a reparative process had but just commenced.
In another case, twenty-four weeks and four days after similar inci-
Bions, be found them completely and firmly united by fibrous tissue
formed out of the substance of the healthy cartilage. The cut surfaces
of the cartilage were very uneven, and were hollowed into small pits,
produced by the half-destroyed cartilage-cells, the former contents of
which were now lying on the surface. No evident change had taken
place in the texture of the cartilage at a little distance from the cut
surfaces, except that here and there the intercellular substance pre-
sented a fibrous appearance. The substance uniting the cut surfaces
consisted of a hyaline, granular, and indistinctly striated mass, in which
were numbers of roimded, oblong, elongating, or irregularly-shaped cor-
puscles. A nucleated fibrous membrane, formed by the conversion of
the superficial layers of the cartilage bordering th6 wounds, was con-
tinuous with their uniting medium. ^' The essential parts of the pro-
cess [of union of such incised wounds] appear to be," Dr. Redfern con-
* Aoormal Nutrition in Articular Cartilages : Edinburgh, 1850. And, On the Healing
ofWoands in Articular Cartilages: in the Monthly Journal of Medical Science, Sept., 1851.
i
190 HEALING OF TENDONS.
eludes, " the softening of the intercellular substance of the cartilage,
the release of the nuclei of its cells, the formation of white fibrous tis-
sue from the softened intercellular substance, and of nuclear fibres by
the elongation of the free nuclei.**
Such a process has peculiar interest as occurring in a tissue which
has no bloodvessels, and in which, therefore, the reparative material is
furnished by transformation of its own substance, not by exudation from
the blood. In the same view the results of inflammation of articular
cartilage will have to be particularly noticed.
In membraniform cartilages that have perichondrium, the healing
process is, probably, in some measure modified ; a reparative material
being furnished, at least in part, from the perichondria! vessels. The
cartilaginous tissue was less changed than in Dr. Redfern*8 cases, in an
example of wounded thyroid cartilage that I examined. A man, long
before death, cut his throat, and the wound passed about half an inch
into the angle of his thyroid cartilage. In the very narrow gap thus
made, a gap not more than half a line in width, there was only a layer
of tough fibrous tissue ; and with the microscope I could detect no ap-
pearance of a renewed growth of cartilage. The edges of the cartilage,
to which the fibrous tissue was attached, were as abrupt, as clean, and
as straight as those would be of a section of cartilage just made with a
very sharp instrument. The cut cartilage was unchanged, though the
union between it and the new-formed fibrous tissue was as close and as
firm as that of the several parts of a continuous tissue. The perichon-
drium on both sides was equally firmly attached to the fibrous bond.*
In some instances (but I suppose in none but those of cartilages
which have a natural tendency to be ossified in advancing years) the
fractures of cartilage may be united by bone. This commonly happens
in the fractures of the costal cartilages ; and it has been noticed in
fractures of the thyroid cartilage. The union of a fracture of the car-
tilaginous portion of a rib is usually effected, as that of one in the osse-
ous portion is, by an inclosing ring of bone, like a provisional external
callus ; and the ossification extends to the parts of the cartilage imme-
diately adjacent to the fracture.f
Healing of Tendons. — I have already often referred to the phenomena
that follow tlie division of tendons by subcutaneous and by open wounds ;
but the practical interest of the subject will justify my giving » con-
* A case has recently been reconied by Mr. Edwards (Edin. Month. Med. Joiir. March,
I8r>l), in which ^ere was such complete reunion (apparently cartilaginous), of the tracheal
rings of an infant, who died about twelve months after the operation of tracheotomy had
been performed, that no scar was visible. No microscopic examination of the new material
was, however, made.
f Museum of the College, No. 377 ; and of St. Bartholomew's, Ser. iii, Nos. 48, 73. Nu-
merous examples of the partial repair of larger injuries of articular and other cartilages will
be found in Hildebrandts Anatomie, B. i, p. 306.
HEALING OF TENDONS. 191
nected account of the process, as I observed it in a series of numerous
experiments performed, with the help of Mr. Savory, on rabbits from
three to six months old. Such experiments are, I know, open, in some
measure, to the same objection as I showed in the last lecture to those
on fractures in the lower animals ; but the few instances in which ex-
aminations have been made of human tendons, divided by subcutaneous
section, have shown that the processes in man and in animals are not
materially different. The chief differences are, we may believe, that,
as in the repair of bones, the production of reparative material is more
abundant and its organization more speedy, in animals than in man.
I have already, in the eighth lecture, stated generally the differences
in the several consequences of open and subcutaneous wounds. In the
case of divided Achilles-tendons, the disadvantages of opcm wounds, i. e.,
of wounds extending through the integuments over and on each side of
the tendon, as well as through it, were as follows : 1. There were alway-s
more inflammation in the neighborhood of the wound, and more copious
infiltration of the parts, than in a subcutaneous division of the tendon
in the same rabbit ; 2. Suppuration frequently occurred, either between
the retracted ends of the divided tendon, or beneath its distal end ; 3.
The skin was more apt to become adherent to the tendon, and so to
limit and hinder its sliding movements, when the healing was completed ;
4.. The retracted ends of the tendon were more often displaced, so that
their axis did not exactly correspond with each other, or with that of
the reparative bond of union.
Such mishaps were often observed in the open wounds, but were rare
after the subcutaneous operations. In the cases of open wounds, they^
were avoided as often as the wound through the integuments healed
quickly ; and, whenever this happened, the case proceeded like one in
which the subcutaneous division had been made. It was evident that
the exposure of the wounded parts to the air did little harm, if it was
continued for only a few hours ; a fact that may be usefully remem-
bered when operations must be performed on tendons which it is not
convenient to divide unseen.
These same cases of speedy healing of the opening in the integuments
served to show, that it is unimportant for the healing of divided Achil-
les-tendons, whether the connective tissue sheath or covering of the ten-
don be divided or not. In all the cases of open division in these ex-
periments, it was completely cut through ; yet, when the external
wound healed quickly, the union of the divided tendon was as speedy
and as complete as in any case of subcutaneous division in which it
might be supposed that the sheath of the tendon was not injured.
I will describe now the course of events after subcutaneous division of
the Achilles-tendon ; stating only what was generally observed, and illus-
trating it, as far as may be, with the annexed diagram (Fig. 25), in
which, aa in longitudinal sections, a may represent the natural condi-
HIALIHQ OF TBNDOHS.
tion of the tendon and its muscles, and the succeeding figures the effects
of its division and the Bucceesive stages of its repair.*
At the instant of the division, the ends of the tendon separate to the
digtance of nearly an inch, the upper portion of the tendon heing drawn
up the leg by the action of the gastrocnemius and soleus muscles (b).
The retraction is comparatively much greater than is usual in operations
on the human Achilles-tendon; for where these are done, the muscles
are seldom capable of strong or extensive contraction. It is in all
cases to he rememhered that the separation is cffectetl entirely by the
withdrawal of the upper portion of the tendon; the lower, being not
connected with muscle, remains with its end opposite the wound. To
Fig. 2-'>,
this we may ascribe the general fact that the reparative process is more
active, and the inflammatory process less so, at the upper than at the ■
lower portion of the tendon : for the latter lies in the very centre of the
chief inflammatory action ; while the former is removed far from it,
being drawn away, at once from the seat of the injury, and from even
the slightest exposure to the air.
I have already said that very little blood is effused in the subcu-
taneous operations. Commonly, only a few blotches of extravasation
appear in and near the space from which the upper part of the tendon
is retracted (b). The first apparent consequence of the division of the
* Tlie account here givan Hgrees in all cuenlial reipects with that b/ Lebert. in liii Ab-
bandlungen . . . tier pmlic. Cliirurgie, p. 41^13. Neither do \he accoiinla maleriBlly diSor,
etcept in being leaa tniniite, wliioh are given by Von Ammon (Do Phy»iologia TenDiotiiia;),
Duval (Bull, de I'Acad. Bofnle de MMecine, IS37), and Diiparc [Neilerland«:h Lbdoci.
1837).
HEALING OF TENDOTNS. 193
•
tendon is the effusion of a fluid or semifluid substance, which, like the
product of common inflammation, quickly organizes itself into the well-
known forms of lymph- or exudation-cells. These, speedily becoming
more distinctly nucleated and elongated, undergo the changes which -I
mentioned in describing the development of cells in granulations. The
exuded lymph makes the tissues at and near the wound succulent and
yellow^ like parts infiltrated in anasarca. The bloodvessels near the
divided tendon enlarge, as in an inflamed part, and appear filled with
blood (b, c). The exudation, together with the enlargement of the ves-
sels, swells the parts, so that the skin is scarcely at all depressed be-
tween the separated ends of the tendon. But in well-made subcuta-
neous sections, this inflammatory product is of small amount, and takes,
I believe, little or no share in the healing of the injury ; for the exuda-
tion ceases after the first twenty-four hours, and I think that its cells
are not developed beyond the state in which they appear spindle-shaped.
I have never seen indications of their forming filaments of connective
tissue.
In rabbits, forty-eight hours usually elapse before there are distinct
signs of the production of the proper reparative material. This is de-
posited in the fibro-cellular tissue that lies between and close round the
separated ends of the tendon, as well as in the interspaces of the ten-^
dinous fasciculi of those ends. It thus swells up the space between the
separated ends, and makes the ends themselves larger, and somewhat
ruddy, soft, and succulent. Some portion, at least, of it being deposited
where the inflammatory effusion was, one finds their constituents mingled ;
but I believe that, while the proper reparative material develops itself,
the product of the inflammation is either arrested in its development,
or even degenerates ; its cells shrivelling and gradually wasting.
I need not now describe the mode of development of the reparative
material provided for divided tendons : for I have taken it as a typical
example of the development of lymph into nucleated blastema, and
thence into fibrous tissue (p. 139). To the naked eye it appears after
three days as a soft, moist, and grayish substance, with a slight ruddy
tinge, accidentally more or less blotched with blood, extending from
one end of the tendon to the other, having no well-marked boundary,
and merging gradually into the surrounding parts (c). In its gradual
progress, the reparative material becomes commensurately firmer,
tougher, and grayer, the ruddiness successively disappearing from the
circumference to the axis ; it becomes, also, more defined from the sur-
rounding parts, and, after four or five days, forms a distinct cord-like
vascular bond of connection between the ends of the tendon, extend-
ing through all the space from which they have been retracted, and for
a short distance ensheathing them both (d, e).
As the bond of connection thus acquires toughness and definition, so
the tissue around it loses its infiltrated and vascular appearance : the
bloodvessels regain their normal size, the inflammatory effusion clears
\
194 HEALING OP TENDONS.
up, and the integuments become looser, and slide, more easily. In
every experiment, one finds cause for admiration at the manner in
which a single well-designed and cord-like bond of union is thus gradu-
ally formed, where at first there had been a uniform and seemingly
purposeless infiltration of the whole space left by the retraction of the
tendon.
With the increase of toughness, the new substance acquires a more
decidedly filamentous appearance and structure. After the fourth day,
the microscope detects nuclei in the previously homogeneous fibrine-like
reparative material : and after the seventh or eighth day there appear
well-marked filaments, like those of the less perfect forms of fibrous
tissue. Gradually perfecting itself, but with a rate of progress which
becomes gradually less,* the new tissue may become at last, in all ap-
pearance, identical with that of the original tendon. So it has happened
in the valuable specimens presented to the Museum of the College by
Mr. Tamplin.f They are the Achilles-tendon and the tendons of the
anterior and posterior tibial muscles of a child nine months old, in whom,
when it was five months old, all these tendons were divided for the cure
of congenital varus. The child had perfect use of its feet after the
operation, and, when it died, no trace of the division of any of the ten-
dons could be discerned even with microscopic aid.
In the instances of divided human tendons, less retraction, I have
already said, takes place than in those of lower animals. The con-
necting bond is therefore comparatively shorter ; and it is yet more
shortened when, like a scar, it contracts as it becomes firmer. It is
impossible, therefore, to say what length of new material was, in this
case, formed into exact imitation of the old tendon. But, however little
it may have been, such perfect repair as these specimens show is ex-
ceedingly rare. More commonly the differences between the original
tendon and the new substance remain well-marked. The latter does
not acquire the uniform arrangement of fibres, or the peculiar glisten-
ing thence accruing to the normal tendons : it is harder and less pliant,
though not tougher ; its fibres appear irregularly interwoven and en-
tangled, dull-white, like those of a common scar. And these differences,
though as time passes they become gradually less, are always seen when
a longitudinal section is made from behind, through both the ends of
the tendon and the new substance that ensheaths and connects them.
In such a section (as in Fig. 25, B), one sees each of the retracted ends
of the divided tendon preserving nearly all its peculiar whiteness, only
somewhat rounded or misshapen, swollen, and imbedded in the end of
* One may remark this as a general fact, that when once the reparative process has com-
menced, much more appears to be done in it in the first few days than in any equal subse-
quent period of time. It may be another instance justifying the general expression, that
pro<luction is easier than development or improvement, and that the earlier or lower de-
velopments require less organizing force than the higher or later.
t Nos. 358, 359, 360.
HEALING OF MUSCLES. 195
the new substance, which is always grayer, or less glistening, and looks
less compact and regular. In the retracted ends of the tendon, one
may discern the new substance mingled with the old and interposed
between its fasciculi, with which one may believe it is connected by the
finest dovetailing.*
The strength, both of the new substance itself and of its connection
by intermingling with the original substance, is worthy of remark. To
test it, I removed from a rabbit an Achilles-tendon, which had been
divided six days previously, and of which the retracted ends were con-
nected by a bond of the size and texture usual at that period of the
reparative process. I suspended from the half-section of this bond
gradually increased weights. At length it bore a weight of ten pounds,
but presently gave way with it : yet we may suppose the whole thick-
ness of the bond would have borne twenty pounds. In another experi-
ment, I tried the strength of a bond of connection which had be^n ten
days forming : this, after bearing suspended weights of twenty, thirty,
forty, and fifty pounds, was torn with fifty-six pounds. But surely the
strength it showed was very wonderful when we remember that it was
not more than two lines in its chief diameter, and that it was wholly
formed and organized in ten days, in the leg of a rabbit scarcely more
than a pound in weight. With its tenacity it had acquired much of
the inextensibility of^the natural tendon. It was indeed stretched by
the heavy weights suspended from it^^ yet so slightly that I think no
exertion of which the rabbit was capable would have suflSced to extend
it in any appreciable degree. f
The Sealing of Muscles, subcutaneously divided, presents many things
exactly similar to those just described as observed in the healing of
tendons similarly divided, and the structure of the connecting repara-
tive bond is of the same kind ; new muscular fibres, I believe, are never
formed. But, in the experiments which I made on the triceps extensor
brachii, and the tibialis anticus of rabbits, there was always observed a
peculiar inversion, subsidence, or tucking in of the muscular fibres at
the divided part ; so that nearly all the fasciculi directed their cut ends
towards the subjacent bone or fascia. Thus it sometimes appeared to
happen that though the retracted portions of the muscle were imper-
fectly united, yet the action of the muscle was not lost : for one or both its
ends, acquiring new attachments to the subjacent parts, could still act,
though with diminished range, upon the joint over which its fibres passed.
* The appearances are shown in specimens in the College Museum, Nos. 348 to 354 ;
and in those from the experiments on rabbits in the Museum of St. Bartholomew's.
f Reference may be made to the observations of Mr. W. Adams " On the Reparative
Process in Human Tendons after Division,*' London, 18C0, as confirming generally what
is described in the text. In this work an abstract of the various opinions entertained by
surgeons on the process of reparation of these structures has been incorporated in the form
of an appendix.
196 HEALING OP ARTERIES AND VEINS.
In general it appeared that the reparative material was less quickly
produced than after division of the tendons ; but this might be because
of the greater violence inflicted in the operation, more than because of
the structure of the divided parts. The usual method and end of the de-
velopment of the reparative material were the same as after division of
the tendons ; and at length, but always, I think, more slowly than with
them, the ends of the retracted portions became inclosed in a tough
fibrous bond of union.
After the formation of this bond, the healing of divided muscles is
improved, both by the clearing up of the surrounding tissues infiltrated
with inflammatory products, and by the contraction of the new bond,
which thus draws together the retracted portions of the muscle, so that
they may nearly coalesce. Thus, in a man who had cut his throat long
before his death, and had divided the left sterno-hyoid, omo-hyoid, and
sterno-thyroid muscles, I found that the ends of these muscles, though
they must at first have retracted considerably, had all been drawn to
attachments on the cricoid cartilage, over which their several portions
nearly united. '
The Healing of Injured Arteries and Veins is commonly a more
complicated process than those already described, on account of the
changes that ensue in the blood that is stagnant within, or shed around,
the injured vessel.*
Small wounds of either arteries or veins may heal by immediate union,
or primary adhesion, as those of any other tissue may, and the blood
shed into the adjacent tissues may be absorbed as from common ecchy-
mosis. An artery divided in only part of its circumference, although
it may be for a time contracted, yet does not remain so ; neither is it
commonly, in such a case, obstructed by clot within its can^l. Hence,
after such wounds, the pulse in the distal or lower part of the artery is
often unaffected. After the first outrush of blood, some that remains
extravasated among the tissues usually clots, and covers the wound in
the artery ; but the closure is often ineffectual, or only for a time, and
fresh bleedings ensue, either increasing the accumulation of extravasated
blood, or pushing out the clots already formed. In this way, with re-
peated hemorrhages at uncertain intervals, the wound in an artery is
often kept open, and at the end of two or three weeks may show no
trace of healing, but, rather, appear widened and with softened everted
edges. In such a case, it is possible that the wound in an artery may
still heal by granulations, either rising from its edges or coalescing over
it from adjacent parts ; but the event is too unlikely to justify the wait-
ing for its occurrence, if there be opportunity for surgical interference.
* Nearly all that follows relates to the healing of wounds of arteries. The process ia
veins appears to be essentially the same, but more quickly accomplished. See StiUinjj^:
"Die natiirlichen Processe bei der Heilung durchschlungener Blutgefa^tse.'* Eisenach, 1834,
p. 147 and 289.
HBALINO OF ARTERIES AND VEINS. 197
In the case of an artery divided quite across, three chief things are
to be considered ; namely, the natural immediate arrest of the bleeding,
the closure of the two orifices, and the (disposal of the blood that may
become stagnant at and near the ends of the divided vessels.
The bleeding is arrested, mainly, by the contraction of the muscular
coat of the artery. Stimulated by the injury and by exposure to the
air, and relieved from much of the pressure of the blood, whose onward
course is less resisted, the muscular tissue of the divided artery contracts
and closes, or, at least, diminishes, the canal. In some instances the
contraction is narrowly funnel- shaped or like the neck of a Florence
oil-flask, and the end of the artery may be open, while, at a little distance
within, its canal is closed or much narrower, and this contracted part is
filled with a clot. In some, the exterior layers of the muscular fibres
seem to contract rather more than the interior, and the end of the artery
appears prominent or pouting. Many, perhaps trivial, differences of
this kind may be noticed in different arteries cut across in amputations.
Moreover, the processes for the stoppage of bleeding are not equally
effective in the upper and lower ends of a divided artery, for whilst the
upper end may be, and remain, permanently closed, the lower end may
reopen, and bleeding be renewed from it, some time after the wound
has been inflicted.
The retraction of the divided artery within its sheath, or among the
adjacent tissues, assists to stay the bleeding, by giving opportunity for
the blood to become diffused, as it flows through the tissues that col-
lapse over the end of the artery before it closes. But the degree to
which this retraction can take place is very uncertain. It depends
chiefly on the laxity or the closeness of the attachment of the artery to
the surrounding tissues, and on the extent to which they with it are
divided, and with it are capable of retraction. In amputations, one sees
many differences in these respects. Arteries divided close to ligament-
oas parts and the origins of muscles appear much retracted, because
the tissues about them are scarcely at all drawn back ; so it is in am-
putations j[u8t below the knee : but those that are divided where there
18 much areolar tissue, or where muscles are far from their origins, as
in the middle or lower part of the fore-arm, appear less retracted, be-
cause these surrounding parts are retracted as much or more than they.
In Kke manner, arteries from which branches are given off just above
the place of division retract less than others, the branches holding them
in place.
Equally various is the degree in which the bleeding from a wounded
artery is arrested by the blood collecting around it, and in front of its
orifice. It depends mainly on the degree of retraction of the artery,
and on the facility with which the blood can escape through the exter-
nal wound. It is assisted, in case of large hemorrhage, by the weaken-
ing of the action of the heart, and, perhaps, by the readier coagulation
of the blood which ensues in syncope.
198 HEALING OF ARTERIES AND VEINS.
The eflScacy of these means for the arrest of bleeding from all but the
principal arterial trunks is evident enough immediately after the am-
putation of a limb. However many arteries may need ligature, they
are probably not more than a tenth of those that were just now traversed
by quick streams of blood. The rest are already closed by their own
muscular action, needing no assistance, from a diminished action of the
heart, or the effusion of blood around them.
I know no observations showing the method of healing and permanent
closure of the small arteries that thus spontaneously cease to bleed. All
the accurate inquiries that I am aware of relate to the closure of the
torn umbilical arteries, which have hardly a parallel in other vessels, or
else to the more complicated cases of large arteries on which ligatures
have been tied, or which have been closed by some artificial means, such
as the *' Durchschlingung" of Stilling; a defect much to be regretted,
since the ligature, or any similar means, introduces such a disturbance
into the process of repair, as makes it a morbid process, however advan-
tageous its end may be. Indeed, when a divided artery is tied, the
injury to be repaired is not that of the wound, but that of the ligature ;
an injury in which a bruised wound dividing the middle and internal
coats of the artery, a bruise with continued compression of its external
coat, and the continued presence of a foreign body, are superadded to
the injuries which preceded the application of the ligature.
For simplicity's sake, let us consider the repair of such an injury in
only that part of an artery which is above the ligature, i. «., nearer to
the heart. The changes in the part beyond the ligature are, according
to Stilling, the same, but more quickly accomplished.
Now, in this repair, three parts are chiefly concerned ; namely, (1)
the injured walls of the vessel at and immediately adjoining the liga-
ture ; (2) the part of the vessel between the ligature and the first branch
above it, through which the blood can flow off; and (3) the blood which,
within the same part of the vessel, i, e., between the ligature and the
first branch nearer to the heart, lies nearly stagnant. The healing of
the artery may indeed be accomplished without the help of this blood,
but certain changes in it commonly concur with the rest of the process.
(1.) The injured walls of the vessel, and the tissue immediately around
them, inflame, and exudation of lymph takes place in them especially at
and just above the divided parts of the coats constricted and held in
contact by the ligature. Thus, as by primary adhesion, or by an ad-
hesive inflammation, the wound made by the ligature in the middle and
internal coats is united ; and, through the same process, this union is
strengthened by the adhesion of these coats to the outer coat, and of the
outer coat to the sheath or other immediately adjacent tissues. There
is a general adhesion of these parts to one another; they appear thick-
ened, infiltrated, and morbidly adherent : beneficial as the result is, it
is the result of disease. Through the same disease, the portion of the
outer coat of the artery included within the ligature sloughs and is
HEALING OF ARTERIES AND VEINS. 199
brought away,* or it ulcerates, and permits the removal of the ligature,
and a more natural process of organization of the inflammatory products
among which it lay, and which its presence had tended to increase.
(2.) When any part of an artery, through any cause, ceases to be
traversed by blood, its walls tend to contract and close its canal. The
application of a ligature brings into this condition all that part of the
tied artery which lies between it and some branch or branches higher
up, through which the stream of blood may be carried off. The walls
of this part therefore slowly contract, gradually reducing the size of
its canal, and, in some instances, probably closing it. Mr. Guthrief
has particularly noticed after the application of ligatures, the curling
inwards of the divided inner and middle coats, which thus in a measure
recede from the contact or proximity of the ligature. There is not in
this, as in the last described part of the process, any disease : the con-
traction is only the same as that of the ductus arteriosus, the umbilical
arteries, and other vessels, from which, in normal life, the streams of
blood are diverted ; and the closure may, as in them, according to Ro-
kitansky,;^ be assisted by deposit from the blood thickening with an
opaque white layer the internal coat. The time occupied by this con-
traction, and its extent in length along the artery, are too various to
be stated generally. When it is permanent, the coats of the artery, at
its completion, waste, lose their peculiar structures, and are slowly
transformed into a fibrous tissue, such as that which composes the solid
cord of the ductus arteriosus.
(3.) Respecting these two consequences of the application of liga-
tures, little diflFerence of opinion can exist ; and it may be repeated, that
either of these may suflSce for the safe closure of the artery. Thus, on
the one hand, we sometimes see an artery pervious to the very end of
a stump, but there safely closed at the seat of ligature ; and on the
other, the naturally torn umbilical arteries of animals, and, I suspect,
the arteries which in common wounds are divided and spontaneously
cease to bleed, are closed and obliterated without inflammation. How-
ever, much more commonly, the blood contained in and near the end
of the tied artery becoming stagnant, concurs, with both the processes
just described, to the closure of the canal.
Concerning this third constituent of the process, more questions have
been raised. I shall describe it from the admirable observations of
Stilling§ and Zwicky.|| They were made in a large series of experi-
ments on the arteries of animals : those of Stilling refer chiefly to the
changes visible to the naked eye, those of Zwicky to the more minute.
When an artery is tied, the blood, as already said, becomes nearly
* See a specimen from a tied subclavian artery in the Museum of St. Bartholomew's.
t Commentaries on the Surgery of the War, 1853.
X Pathologische Anatomie, B. ii, p. 623.
5 Die naiflirl. Processe bei der Heilung durchschlungener Blutgefasse. Eisenach, 1834.
I Die Metamorphose des Thrombus. Zurich, 1845.
200 HEALING OF ARTERIES AND VEINS.
Stagnant in the canal, from the ligature upwards to the first principal
branch. In an uncertain time, varying from one to eighteen hours, a
part of this blood coagulates ; and the clot commonly assumes a more
or less conical form. The base of this " conical clot,** "internal ob-
turator,** " plug,** or " thrombus,** rests in and fills the end of the ar-
tery, at the wound made by the ligature ; its apex usually lies nearly
opposite the first branch above, in the axis of the artery : it is sur-
rounded by fluid, but still nearly stagnant, blood, which, except at its
base, intervenes between it and the internal surface of the artery. At
its base, and higher up if it fills the artery, the clot is dark and soft,
like a common blood-clot ; its upper part and apex are denser, harder,
and whitish, like coagulated fibrine ; and layers of white substance are
often gradually superadded to its middle and apex, and increase its
adhesion to the walls of the vessel.
In course of time, the clot becomes marked with paler spots, and
then porous, spongy, and cavernous, as if it were being gradually chan-
nelled from its surface towards its central parts. In this state, in-
jection impelled into the artery will enter and distribute itself in the
clot, making it appear vascular, or like a cavernous tissue.* While
thus changing, also, it becomes gradually more decolorized, passing
through ruddy, rosy, and yellowish tints, till it is nearly colorless. As
it loses color it gains firmness, and its base and the greater part of its
length become more firmly adherent to the inner surface of the artery,
directly or through the medium of the lymph deposited on it. In this
increasing firmness, the clot, moreover, is acquiring a more definitely
fibrous texture ; and, as the same change is gradually ensuing in the
inflammatory products deposited near the ligature, the clot and they
unite more firmly than before. The walls of the artery, also, gradually
closing in on the clot, unite with it ; and, finally, as they also lose their
peculiar texture, and become fibrous, the clot, and they, together, form
the solid fibrous cord by which the tied portion of the artery is replaced;
a cord which commonly extends, as did the clot, from the seat of the
ligature to the first principal branch above it.
The minuter changes in the clot, associated with those visible to the
naked eye, are, chiefly, that it acquires a fibrous or fibro-cellular tex-
ture, and becomes vascular. I have already said (p. 135), that Zwicky
has traced the development of the fibrine of the clot into fibrous tissue
through the formation of nucleated blastema ; and, probably, I need
not add to the descriptions of this process already drawn from other
though similar instances of it (pages 143 and 193). The development,
or, at least, the later part of it, is accomplished much more slowly than
♦ It was such an injection, probably, that half deceived Hunter into the belief that he
had found the beginning formation of new bloodvessels in the clot (Works, vol. iii, p. 119 ;
and Museum of the G:)llege, No. 11); and such led Stilling into oneof the few errors in his
essay, inducing him to believe that the clot thus became vascular independently of the ves-
sels of the surrounding parts.
HEALING OF DIVIDED NERVES. 201
in the reparative material of tendons in rabbits ; needing more than
ten weeks in the clots formed in dogs, and more than two years in those
in men. The retardation may depend in some measure on the presence
of the blood-corpuscles in the clot ; for these, though they seem not to
affect, or take part in, the development of the fibrine, yet probably, as
they suffer degeneration preparatory to removal, may retard it.*
The bloodvessels usually enter the organizing clot, in dogs, in the
fourth week, when already it has acquired a nucleated and imperfectly
fibrous tissue, and firmness in the place of the spongy texture from
which it had derived a spurious appearance of vascularity. They pass
into it, apparently, from the vessels formed in the lymph exuded within
the artery, in and just above the situation of the ligature ; hence they
enter its lower part, and gradually extend towards its apex.
Such is the important process for the healing of tied arteries. In ap-
plying the description drawn from experiments on animals to the cases
of human arteries, the same allowance must be made as in the repairs of
fractures and of divided tendons. The process is less speedy, less sim-
ple, less straightforward (if I may so speak), more prone to deviate and
to fail, through excess of that disease, by a measured amount of which
the security of the artery is achieved.f
The Healing of Divided Nerves may be accomplished in two methods,
which may be named, respectively, primary and secondary union, and
may, probably, be compared with the processes of primary adhesion
(p. 149), and of connection by intermediate new-formed bonds (p. 191).
I know no instances in which nerves healed in the first method have
been examined, but the nature of the process may be explained by the
history of a case in which it occurred :
A boy, eleven years old, was admitted into Saint Bartholomew's
Hospital, under Mr. Stanley, with a wound across the wrist. This
wound, which had been just previously made with a circular saw, ex-
tended from one margin to the other of the forearm, about an inch above
the wrist-joint. It went through all the flexor tendons of the fingers
and thumb, dividing the radial artery and nerve, the median nerve and
artery, and extending for a short distance into the radius itself. The
ulnar nerve and artery were not injured ; the condition of the inter-
OBseous artery was uncertain, but the interosseous ligament was exposed
at the bottom of the wound. Half an inch of the upper portion of the
divided median nerve lay exposed in the wound, and was distinctly ob-
* The chaDges ensuing in the blood-corpuscles are described by Zwicky ; but I omit them,
since they take no evident part in the reparative process, and are, as yet, not clearly ascer.
tuned.
f Rokitansky (b. ii, p. 616) may be referred to concerning some events in the process
which are not yet.clearly ascertained ; such as the amount to which, in some cases, the clot
may be absorbed, and the share taken by deposit from the blood producing opaque white
thickeoing of the inner coat of the artery.
14
L
202 HEALING OF DIVIDED NBRYBS.
served and touched by Mr. Stanley, myself, and others. All sensation
in the parts supplied from the radial and median neryes below the wound
was completely lost directly, and for some days after the injury.
The radial artery was tied, and the edges of the wounded integuments
put together. No particular pains were taken to hold the ends of the
divided median nerve in contact, but the arm was kept at rest with the
wrist bent.
After ten days or a fortnight the boy began to observe signs of re-
turning sensation in the parts supplied by the median nerve, and these
increasing, I found, a month after the wound, that the nerve had nearly
recovered its conducting power. When he was blindfolded, he could
distinctly discern the contact of the point of a pencil with his second
finger, and the radial side of his third finger ; he was less sure when
his thumb or his forefinger was touched, for though generally right, he
sometimes thought one of these was touched when the contact was with
the other ; and there were a few and distant small portions of the skin
supplied by the median nerve from which he still derived no sensation
at all.
Now all this proves that the ends of the divided median nerve had
coalesced by immediate union, or by primary adhesion with an exceed-
ingly small amount of new substance formed between them. In the
ordinary secondary healing of divided human nerves, twelve months
generally elapse before, if ever, any restoration of the function is ob-
served ; in this case, the nerve could conduct in a fortnight, and per-
haps much less, after the wound. The imperfection of its recovery is
just what one might expect in such a mode of union. One might antici-
pate that some of the fibres in one of its portions would fail to be united
to any in the other portion : and the parts supplied by these filaments
would necessarily remain insensible. So, again, one might expect that
some of the fibres in one portion would unite with some in the other,
with which they were not before continuous, and which supplied parts
alien from those to which themselves were destined ; in all such disloca-
tions of filaments there would be confused or transferred sensations.
But, among all the fibres, some would again combine in the same con-
tinuity in which they had naturally existed ; and in these cases the
function would be at once fully restored.*
* I saw this boy again nearly a year af\er the injury. He had almost perfect sensation
in all the distribution of the median nerve, except in the last phalanges of the thumb and
fore-finger. These had not decreased or changed in texture; but they were very liable to
become cold, and he came to the hospital because large blisters had formed on them. He
had been warming his hands at an open fire, and the heat, which was not uncomfortable to
the rest of the hands, had blistered these parts, as boiling water would have blistered healthy
ones. He had almost completely recovered the movement of his fingers. Schiff in his
Physiology (p. 123), remarking on this and the case immediately following, states that the
rapid union and recovery of sensation observed in them corresponds with what he has
so frequently found in the warm-blooded animals on which he has experimented He ma-
cribes the quick recovery to the wound being made with a sharp cutting instrument, and
HEALING OP DIVIDED NERVES. 203
While this case was under observation, Mr. Gatty sent me, with the
permission of Mr. Heygate, in whose practice the case occurred, the
following particulars of a similar instance of repair : *
A lad, near Market Harborough, thirteen years old, had his hand
nearly cut off at the wrist-joint by the knife of a chaff-cutting machine.
The knife passed through the joint, separating a small portion of the
ends of the radius and of the ulna, and leaving the 'hand attached to
the fore-arm by only a portion of integument about an inch wide, con-
nected with which were the ulnar vessels and nerve, and the flexor
carpi ulnaris muscle — all uninjured. The radial artery and some small
branches being tied, the hand and arm were brought into apposition,
and after removing a small portion of extensor tendon that protruded,
were retained firmly with adhesive plaster and a splint of pasteboard.
The wound went on very well, and was left undisturbed for a week.
The warmth of the hand returned ; in ten or twelve days after the in-
jury there was slight sensation in the fingers, but in the thumb none
was discernible till more than a fortnight had elapsed.
Finally, the sensation of the hand and fingers, and most of their
movements, were perfectly restored.
In this case, again, it seems impossible to explain the speedy resto-
ration of the conducting power of the nerve, except on the supposition
that its divided fibres had immediately reunited. We have no evidence
that new nerve-fibres could in so short a time be formed : all the cases
of less favorable healing show that they require a year or more for their
formation.
I need hardly add the practical rule we may draw from these cases.
It is, briefly, that we may, with good hope of great advantage, always
endeavor to bring into contact, and immediately unite, the ends of di-
vided nerves ; and that we need not in all such cases anticipate a long-
continued suspension of the sensation and other functions of the part
the nerves supplied.
The secondary healing of divided nerves presents many features simi-
lar to that of divided tendons. A bond of new substance is formed,
which connects the ends of the retracted portions of the nerve, and in
which, though at first it is like common reparative material, new nerve-
fibres form, and connect themselves with the fibres in the portions above-
and below. I need not dwell on the formation or development of this
connecting bond : the subject is amply treated in several works on phy-
siology ;* and it is thoroughly illustrated, so far as the appearances tO:
the naked eye are concerned, by the valuable series of preparations
states that such wounds, when unaccompanied by loss of substance, heal within a few days.
MOTeover, he considers that, next to the connective tissue, nerves, when cleanly divided, heal
more readily than any other texture, surpassing in this respect even the bones. On the other
hand, if the nerve be greatly injured previous to, or during, the section, as by pinching it
widi the forceps, &o., then the process of restoration takes a much longer time.
* See especially Mtlller^s Physiology, by Baly, i, p. 457 ; Valentin's Physiologic, i, p.
702; Hildebrandt's Anatomie, i, p. 291 ; SchiflTs Physiologic, i, 1859.
L
204 HEALING OF DIVIDED NERVES.
given to the Museum of the College by Mr. Swan.* Dr. Waller, f by
watching the process which follows the division of the glosso-pharyn-
geal nerve in frogs, has concluded that, after a nerve is divided, the
old fibres in the distal portion never recover their functions. They
degenerate, and new fibres gradually form in the whole length of the
nerve from the place of division to the peripheral distribution. These
new fibres connect themselves with those in the connecting bond of re-
pair, and through these with the old fibres in the proximal portion of
the nerve.J
The repair of nervous centres has been comparatively little studied.
Flourens has indeed shown§ that deep wounds, both of the brain and
spinal cord, unite, and that a restoration of function occurs. The
experiments of M. Brown-S6quard|| have proved that, after complete
division of the mid-dorsal part of the spinal cord of pigeons, and after
division of more than half of that of guinea-pigs, the sensibility and
movements of the hinder part of the body may be almost completely
restored in about twelve months ; and that the substance by which the
injury of the cord is healed contains, with connective tissue, abundant
well-formed nerve-fibres connected with those of the cord above and
below, and sparing nerve-cells.
Schrader*s experiments of dividing and removing small portions of
the cervical ganglia, and the ganglion of the vagus, of rabbits, found
union by fibrous bonds, but no regefieration of ganglion-cells, after
eleven weeks. ^ Valentin's similar experiments had scarcely a more
positive result.**
* Nos. 2169 to 2175. All these specimens, and the appearances of the formation of new
nerve-fibres which they display, are described and illustrated by Mr. Swan, in his ** Trea-
tise on the Diseases and Injuries of Nerves." In Nos. 2165 to 2168 in the College Muaeum,
Mr. Hunter has shown the formation of the bulb at the ends of divided nerves, and the ex-
tension of nerve-fibres into it.
f London Journal of Medicine, July, 1852.
;|: Some recent investigations would appear to indicate that so complete a disappearance
of the fibres of the distal part of the divided nerve hardly takes place, as Waller had sup-
posed. From these it seems probable, that whilst many of the nerve-fibres lose their con
tents after division, the neurilemma remains, and the regenerative process fills it with the
normal contents. (See Bruch, Schiff, and Lent, in Kolliker's Manual of Mio. Anat 1860.)
Hjelt (Yirchow's Archiv, vol. xix, 1860) believes that the union of these refilled nerves with
the proximal ends of the divided fibres takes place through an increased growth of the nu-
clei of the neurilemma and the interstitial connective substance between the divided ends.
Changes subsequently take place in these nuclei and the interstitial connective substance
which result in the formation of new nerve-fibres, which serve as a bond of connection be-
tween the two ends.
2 Recherches exper. sur les syst. nerv.
II Comptes Rendus de la Soc. de Biologic, t. i, p. 17 ; t. ii, pi. 3 ; t. iii, p. 77.
^ Experimenta circa Regenerationem in Gangliis nerveis. Gottingen, 1850.
♦* Physiologic, i, 703. Walter has anew investigated this subject (De regeneratione gan-
gliorum, Bonn. 1853), but his results are mostly negative. In one case, however, he saw,
after excision of the second ganglion of the vagus, in the upper part of the new-formed sweU-
ing, many normal ganglion-cells. He could not satisfy himself that there was any restora-
HEALING OF SKIN. 206
After woimdB and losses of substance of the brain, a large quantity
of new material may be formed to fill up the gap ;* but observations
are wanting to show how much this may contain of proper cerebral sub-
stance. I have found nerve-fibres in it after thirty-three years (see p.
76) ; but in the same specimen there was no appearance of gray matter.f
The last tissue to the healing of which I shall particularly refer, is
the skin. I need not indeed describe the whole process, because nearly
all that was said of the healing processes generally was chiefly illustrated
by instances of wounds involving the skin. Yet it may be useful to
indicate the skin as, on the whole, the part which, being most exposed
to injury, is capable of the best repair ; that which heals most com-
monly by the immediate union, most quickly by primary adhesion ; that
which produces the most rapidly and securely organizing granulations.
The healing of skin is further favored by its extensibility and loose
connection with adjacent parts ; so that, when large surfaces are to be
healed, the contracting granulations can draw over their borders the
loose skin around. Moreover, the new-formed skin imitates the old
skin very well, if we consider the complexity of its structure. I am not
aware that the smooth muscular fibres, or any of the granular struc-
tures of the skin, or hair follicles, are formed in its scars ; but its white
fibrous and elastic tissues, its connective 'tissue corpuscles,^ its papillae
and epidermis, are all well formed in them.
The new cuticle grows chiefly from the margin of the wound centri-
petally over the surface ; but it may arise, in the midst of a raw sur-
face, on granulations, independently of any pre-existing cuticular struc-
tures from which it might be derived. The new epidermal cells, as C.
0. Weber's observations§ would show, are formed by a conversion of
the connective-tissue corpuscles of the superficial layer of granulation-
cells, which lose their spindle-like and assume a polygonal shape. It
is commonly said that the smoothness of a scar is due to the absence
of papillae, but I believe it depends only on the tightness of the new-
formed skin and its want of such wrinkled and furrowed lines as natu-
rally exist. If a thin section be made of the border of a healing wound,
80 as to include the new-formed layer of epidermis, the granulations
tkm of function. Scbiff again thinks that the second ganglion of the vagus is not so pre-
cisely boanded that it could with certainty be said that excision of the swelling had re-
mored all the ganglion-ceils, and that, therefore, those found by Walter may not have been
Dew-fimned cells.
* See especially Ameroann : Versuche iiber das Gehirn und Riiclcenmark. Gottingen,
1787.
f Cases are recorded by Virchow (Gesam. Abband. p. 998) and TUngel (Virchow's
Aicbiv, B. xvi, p. 166), in which nodules of gray cerebral substance are stated to have been
fooad in parts of the brain in which no such masses should have been present. But there
ii no evidence that these formations were occasioned by any previous injury to the parts,
t Billroth, Beitr&ge zur Path. Hist. 1858, Berlin.
S Entwickliing des Eiters, &c. Virchow's Archiv, B. xv.
v
now skinned over will be found, as in the aDnexed diagram (Fig. 26),
presenting the papillary form. They consiflt still of nucleated cells, but
the shape of papillse ia acquired, or rather,
^''C- 2"' is retained ; for the likeness of a granu-
lating surface to a finely papillary one is
i ii'vidcnt, and may be regarded as an ex-
ample of the general tendency of new-
formed atructurea, even in disease, to
assume a plan of construction similar to
that of the adjacent parts. The likeness
exterda to the arrangement of the blood-
vessels ; and the papillary structure is not
lost in the later development of the scar. If the epidermis of a scar
be separated, its under surface will present a series of depressions cor-
responding with the elevations of tlie papillse on which it was adapted.
The subjoined sketch represents the under surface of epidermis so re-
flected from a scar on the arm of a negro : and may illustrate not only
the plan of the papillis, of which it was like a mould, but, by its color,
the complete reproduction of a rete nigrum.*
In concluding the lectures on Repair, and before beginning those on
Inflammation, let me briefly state the rela-
tions of the one process to the other.
It is not becuuse we have any well-defined
\>]fa of inflammation that it is desirable to
rufVr to it, as if it were a standard with
«liich we might compare other organic pro-
cesses; but such a reference seems neccs-
^:iiy, because some idea of inflammation
mingles itself with nearly everything that is
considered in surgical pathology. Nowhere
is this more manifest than in what has been
written in surgical works upon the methods
of repair ; concerning which a general im-
pression seems still to bo, that a process of
inflammation forms part of the organic acts
lallest instance uf repair is accomplished.
Pig. 27.
* For ilie flintier aaiiy or the henling procfis. cspecinlly in Ihe (isiusB and orgsD* DM
menlioned in this lecture, 1 must refer the reailer either to special DeBtises on Ihe patholog;
or those paru, or 10 ibe oliief works on General Anatom;, especially, io relation to rII but
microscopic olwervationa, to thai aC Hildebratidt, »lileil by E. H. Weber ; and 10 the ehapteia
on Reproduction in MUlleri Physiology, by Baly, vol. i, p, 4411, and in Valemin'* Phydo-
logic, i, TOO. The power of ropuir in the cornea is illustrated especially hy Dt. Big)^r, ia
the Dublin JouriiHl of Med, Scienoe, IS37 ; and by Donderii. in ihe Onderxoehingen ....
der Utreobtsche Hoogeschool, D. i, p. 31. The repair of TrHctureit teeth by liori« is de-
.cribed by Mr. Tomee in his •" Dental Surgery." The .Museum of the College has Ilie be^t
■pecimetis, illustrating repair, thai I am acquainleil with.
RBLATIONS OP REPAIR AND INFLAMMATION. 207
Now, the processes we have traced appear to warrant these general
conclusions :
1. In the healing of a wound hj immediate union, inflammation
forms no ^necessary part of the process; rather, its presence always
hinders and may completely prevent it. The healing by immediate
union should be a simple rejoining of the several parts without the
production of any new material ; and in the same proportion as, in any
case, inflammatory matter is effused, either in or between the wounded
parts, in that proportion does the healing deviate from the true and
best process of immediate union.
2. For sfibcutaneous wounds and injuries, as in divided tendons,
simple fractures, and the like, nearly the same may be said. Inflam-
mation is excited by the local injury, but its products form no neces-
sary part of the material of repair ; rather, the more abundant they
are, the more acute the inflammation is ; and the longer it continues,
the less speedy and the less perfect is the process of repair. For here
the necessary or best reparative material is a substance which is pro-
duced without the signs of coexistent inflammation, and of which the
development is difierent from that of the inflammatory products that
are mingled with it. And this, which is most evident in the case of
the healing of subcutaneous injuries by bonds of connection, is probably
equally true in the case of subcutaneous granulations.
3. In the healing of a wound by primary adhesion, or by open granu-
lations, we, usually, have evidence of a process of inflammation, in the
first instance, in the presence of its ordinary signs, in a degree gene-
rally proportioned to the severity and extent of the injury.
4. Still, in these cases, the signs of an inflammatory process are
often absent ; and even when they exist, the process appears necessary
for no more than the production of the organizable matter, and, in the
case of granulations, for the production of only the first portions of it.
The right formation of the cells, and, yet more evidently, their higher
organization jnto connective and other tissues, ensue only while the
signs of inflammation are absent. They are manifestly hindered or
prevented when signs of inflammation are present, or when its existence
may be suspected in consequence of the presence of some irritation, as
a foreign body, dead bone, or the like. The continuance of suppura-
tion, also, during the process of healing, is no proof of the continuance
of inflammation, if the account that I have given of pus be true.
In these two modes of healing, therefore, we may conclude that in-
flammation is sometimes absent, and is, in any case, only partially, and
at one period, requisite ; and that, in regard to its requisite degree, the
least amount with Which an exudation of lymph is possible, is that
which is most favorable to repair.
5. For the process of healing by scabbing, the absence of inflamma-
tion appears to be essential ; indeed the liability of our own tissues to
the in^ammatory process, and to the continued exudation that it pro-
208 PHENOMENA OF INFLAMMATION:
duces, appears to be that which prevents their injories from being healed
as easily and sUrely, by the scabbing process, as nearly all open wounds
are in animals.
Lastly, in certain cases, the artificial production of an inflammatory
process is necessary for repairs for which the natural processes are in-
sufficient or insecure. Among these, are the cases of fractures remain-
ing disunited, and of arteries and veins needing ligatures.
Such may be regarded as the relations of .the reparative process to
that of inflammation, as it is commonly understood ; but I repeat, such
a comparison can be made only for the sake of deference to the general
state of opinion in matters of surgical pathology. In tru(h, we know
less of inflammation than of the reparative process.
LECTURE XIIL
PHENOMENA OF IllFLAMMATION.
It is no more than the truth which Mr. Travers has well expressed
in his work on the " Physiology of Inflammation and the Healing Pro-
cess'*— ^^ that a knowledge of the phenomena of inflammation, the laws
by which it is governed in its course, and the relations which its several
processes bear to each other, is the keystone to medical and surgical
science."
I shall not attempt to define inflammation in any set terms ; for as
yet we are not, I think, in a position to do this. Just definitions can-
not be made in any science till some of its broad and very sure princi-
ples have been established. Such principles we cannot boast to have
yet attained in the study of pathology ; and the attempts at precise
definitions that have been made hitherto, seem to have led to confusion,
or to false and narrow views of truth. Besides, to define inflammation
is the less necessary, because, practically, we all know sufficiently well
what the term implies : we know the signs of the presence of the disease
in all its chief forms ; and, when we watch these signs in any external
part, we see them so often followed by peculiar changes in the part, that
we are justified in recognizing the changes as effiects of inflammation,
and in believing that wherever we find them, the similar or correspond-
ing signs of inflammation have preceded them.
But the very difficulty of exactly defining the process of inflamma-
tion may be our guide to the most hopeful method of investigating it.
When we see such gradual transitions from the normal process of nu-
trition to the disease of inflammation, that we cannot draw a definition-
line between them, we may be sure that the main laws of physiology
are the laws alike of the disease and of the healthy process ; that the
STATE OF THB BLOODVESSELS. 209
same forces are engaged in both ; and that, though interfered with by
the conditions of the disease, they are not supplanted or annulled.
Now, such transitions from the normal processes to that of inflamma-
tion are not rare. We may trace them, for example, in the gradual
passage from the active exercise of the brain, or of the retina, to its
^^ irritation" when overworked, and thence to its complete inflammation
and impairment of structure, after long exposure to what had been a
natural stimulus, or to what, in a less degree, might be so. Or, on the
introduction of medicines, such as certain diuretics, into the blood, we
may trace gradations from the normal increase of the functions of the
kidneys, under what is regarded as no morbid stimulus, to their intens-
est inflammations. Or, again, in the application of an abnormal stimu-
lus, such as that of a heat greater than the natural temperature of the
body, where shall we mark the line at which inflammation begins to
supervene on health ? We may, indeed, say that stagnation of blood,
or effusion of liquor sanguinis, or some exudation, or some degenerative
change in the elements of the affected tissue, shall be the condition sine
({tAd non of inflammation ; we may call whatever falls short of these,
" active congestion," " irritation," or by any other name ; but, in reality,
Buch distinctions are often impossible, and sometimes untrue, and in
Btudy, the terms are convenient for the sake of brevity rather than of
clearness.
Evading, then, the question of the precise definition of inflammation,
I shall endeavor, first, to describe the state of an inflamed part, giving
to the description such a plan and direction as may best help the chief
design— first, of contrasting the inflammatory with the normal method
of nutrition ; and, secondly, of showing that the immediate causes, and
the chief constituents, of the inflammatory state, are to be found in
alterations of those things which are necessary conditions of the healthy
nutrition of a part. It will be easy to connect with such a description
the explanations, so far as they can be given, of the constituent signs or
phenomena of inflammation, — the redness, swelling, heat and pain, and
the disturbed function of the part.
The conditions of the healthy maintenance of any part by nutrition,
are, as illustrated in the earlier lectures — 1st, a regular and not far
distant supply of blood ; 2d, a right state and composition of that blood ;
Sd (at least in most cases), a certain influence of the nervous force ; and,
4th, a natural state of the part in which nutrition is to be effected. All
these are usually altered in inflammation.
I. The supply of blood to an inflamed part is altered, both by the
changes of the bloodvessels, especially by their enlargement, and by the
mode in which the blood moves through them.
The enlargement of the bloodvessels is, I suppose, a constant event
in the inflammation of a part ; for, although in certain parts, as the
eornea, the vitreous humor, and the articular cartilages, some of the signs
210
PHBSOMBNA OP INFLAHM ATIOH:
Pig. 28.
or effects of inflammation may be found where there are natnrall; no
hloodvesselB, yet I doubt whether these ever occur without enlargement
of the Tessels of the adjacent parts, and especially of those ressels from
which the diseased structare derives its natural supply of nutritire ma-
terial, and which may therefore be regarded as its bloodvessels, not leM
than those of the part In which they lie. Thus, in infiammation of the
cornea, the vessels of the. sclerotica and conjunctiva are enlarged, and
in ulceration of articular cartilages those of the surrounding synovial
membrane or subjacent bone.
The enlargement usually affects alike the arteries, the capillaries, and
the veins of the inflamed part ; and usually extends to some distance
beyond the chief seat or focus of the
inflammation. To it we may ascribe
the most constant visible sign of in-
flammation, the redness, as well u
much of the swelling. Its amount is
various ; it may be hardly perceptible,
or it may increase the vessels to two
or three times their natural diameter.
Extreme enlargement is admirably
shown in Hunter's specimen* of the
two ears of a rabbit, of which one was
inflamed by thawing it after it bad been
frozen. " The rabbit was killed when
the ear was in the height of inflamma-
tion, and, the head being injected, the
two ears were removed and dried," A
comparison of the ears, or of the draw-
ings from them (Fig. 28), shows all the
arteries of the inflamed car three or
four times larger than those of the
healthy one, and many arteries that in
the healthy state are not visible, are,
in the inflamed state, brought clearly into view by being filled with blood.
I have repeatedly seen similar enlargements of both arteries, and
veins, and capillaries, in the stimulated wings and ears of bats. The
like phenomena occur in the webs of frogs, and other cold-blooded
animals ; but in these, I think the amount of enlargement is generally
less-t
The redness of an inflamed part always appears more than is pro-
portionate to the enlargement of its bloodvessels; chiefly because the
red corpuscles are much more closely crowded than they naturally are
* Museum of the College, No. 71. See, bIh). Hunter's Works, vol. iii, p. 323. >ni] pl.-n.
f Emmen, who is among the few ihal hove measured it, says it is equal lo oncliair oi
onethitil of the normal diameter of ibe vessels. Lebert says one-sixlh to One-thitd {Gazeito
M«dicale, Mai IS, 1853).
STATE OF THE BLOODVESSELS. 211
in the bloodvessels. The vessels of an inflamed part are not only di-
lated, but appear crammed with the red corpuscles, which often lie or
move as if no fluid intervened between them : their quantity is increased
in far greater proportion than that of the liquid part of the blood.
This peculiarity is even more manifest in the frog than in the bat ;
for in the former, the crowding of corpuscles may occur in vessels that
appear to have undergone no change of size on the application of
the stimulus.*
Another, but a minor, cause of the increased redness of the inflamed
part, is sometimes to be observed in the oozing of the coloring matter
of the blood-corpuscles, both into all the interspaces between them, and
through the walls of the small vessels into the adjacent tissue. During
life this may be noticed, especially when the blood is stagnant in the
vessels, and it may give them a hazy, ruddy outline ; but it is generally
much more considerable after death, when we may ascribe to it no small
portion of the redness that an inflamed part may still present.
In the state of inflammation no new bloodvessels are formed. Many
more may come into view than were at first seen in the part ; but these
are only such as were invisible till the flood of blood-corpuscles filled
and distended them. So it was in the rabbit's ears ; in the healthy ear
no trace can be seen, with the naked eye, of any vessels corresponding
with one of the largest, or with many of those of inferior size, in the
inflamed ear. So it is, too, in microscopic examinations. Within half
an hour after stimulating a bat's wing, many vessels may come into
view which could not be seen before with the same lens, and with which
none can be seen corresponding in the other wing, though doubtless
sach vessels exist there of smaller size.
It is only when the inflammation has subsided, and the lymph exuded
from the bloodvessels begins to be more highly organized, that new
vessels are formed, and pass into the lymph, as if for the maintenance
of its increase or development.f So long as the inflammation lasts,
the in tensest redness in parts naturally colorless, — even such as we
see in acute inflammations of the conjunctiva, or yet more remarkably
in those of periosteum, J or in congestion of the stomach, — is due to the
enlargement of the natural bloodvessels, to their admitting crowded red
* I do not more particularly refer to what is described as the encroachment of the red
blood-oorpuscles on the lymph-space, or the layer of fluid that lies in apparent rest adhering
tD the walls of the vessels. The too pointed description of this layer has led to exaggerated
notions concerning it. Its existence is certain, but it is too thin for any blood-corpuscle to lie
at rest in; and when white corpuscles remain by the walls of the vessels, it is evident that
they do so more because of their own adhesiveness than because a small portion of the
fluid aboat them is at rest.
t Mr. Hunter held this opinion ; but more lately the contrary one has been commonly
beld. See his Works, vol. iii, p. 322.
X As illustrated in Mr. Stanley's plates, plate vii. Fig. 1, which represents a specimen in
the Museum uf St. Bartholomew's, Series i. No. 195. The whole inner surface of the in-
flamed periosteum of a tibia is bright scarlet.
OF INF LA
lind in a much less degree, and, perhaps, in only certain
e diffusion of the coloring matter of the blood,
h enlargcmi^Dt of the bloodvessels a change of shape is com-
pciated. Being usually elongated as well as dilated, they are
i, and made more or less wavy or tortuoua. Thus we
Rhe larger vessels in an inflamed conjunctiva, and, more plainly,
Rritoucal arteries in cases of peritonitis ; bo, too, they are rcpre-
1 the rabhit'a inflamed ear.
pre remarkable change of shape of the small vessels of inflamed
which they become aneurismal or varicose. The first
■ations of this state were published, I believe, by Kollikcr and
, in an account of a case of inflammatory red softening of the
which many of what, at first sight, appeared to be points of
Bvasated blood, proved to be dilatations of capillary vessels filled
I blood. After this they found the same changes, but in a much
f degree, in some cases of inflammation artificially excited in the
|[ins of rabbits and pigeons.* Many, as well as myself, have since
B similar observations, most of which, however, seem to show that
le peculiar dilatation has its scat in the small arteries and veins, oa
Veil as in the capillaries of the inflamed part.
Among the various forms of partial dilatation, some are like gradual
fusiform dilatations of the whole circumference of the vessel ; some like
shorter and nearly spheri-
^'S- -"■ ca] dilatations of it ; some
like round, or oval,
elongated pouches, dilated J
from one side of the wall -J
in short, all the variotirj
of form which we ha^
long recognized in
aneurisms and aneurisij
dilatatioAs of the ,
arteries may be founf
miniature in the smalU
sels of such inflamed g
Some of these fornii
represented in FiJ
from the b
an inflamed pericJ
Frequently, however, as this state of the small vessels has l
served in inflamed parts (and I believe some measure of iti
found in the inflammations of most membranes), f yet, I thinkf
* Zciuchc. nir Witaenecb, Zoologie, B. i, p. 203. Mr. KtttrnBD bud obierTi
ctuni^Nime yoart pTokiuily. See Dr. WiJIiams's PrliuriplPt or Medicine, Sdl
t Leben myt ii It tt consmiii occurrence in ejiperimenial inflBmniBiion* of tj
out lisaue of frogs. (Guzetie Mddicsle, Mai, 22, 18S2.)
STATE OF THE BLOODVESSELS. 218
not assume it to have a necessary or important connection with the
other phenomena of inflammation. It is often observed, as Yirchow'*'
especially has shown, in other, besides inflammatory, diseases ; and, in
all alike, may be referred to a gradual deterioration of the structure of
the vessels, weakening them, and rendering them unable to resist
uniformly the increased pressure of the blood.
Such is the ordinary state of the bloodvessels of an inflamed part :
all dilated and elongated, tensely filled with blood, of which the red
corpuscles are in excess, often wavy and tortuous, and sometimes
variously aneurismal.
But the supply of blood to an inflamed part is affected by its mode of
movement, as well as by the size of the bloodvessels : this, therefore, I
must now describe.
Nearly all the observations hitherto recorded, on the morbid changes
in the movement of the blood, have been made with the webs of frogs ;
and it has been objected that it is not safe to apply conclusions drawn
from them to the case of warm-blooded animals. I have therefore em-
ployed the wings of bats, in which (when one has acquired some art in
quieting them with chloroform or gentle management) nearly all the
phenomena of the circulation, as effected by the application of stimuli,
may be watched as deliberately as in the frog, and in some respects
even more clearly.
I think we may believe that what may be seen in the wings of bats
occurs, in the like circumstances, in all warm-blooded animals. It is
true that, like the other hybernants, the bats, while they are in their
winter-sleep, resemble the cold-blooded animals, in that their tempera-
ture is conformed to that of the external air, and scarcely exceeds it.
It is true, also, that when they are ill-nourished, their temperature,
even in their active state, is comparatively low, ranging from 65° to
80® F., in an atmosphere of 60° ; and that generally they are liable to
much greater diversities of temperature than our own bodies are.f And
* In his Archiv, B. iii, p. 432.
f For instance, I found the temperature of a strong and active Noctule Bat ( Vespertilio
Noeiula) thus various in two days :
April 20th, at noon, after he had been nearly two hours under the influence of chloro-
form, and on awaking had been struggling very actively, his temperature was 99° F. At
9 FJC., having meantime been quiet, hanging by his hind feet, and looking sickly, his tem-
perature was only 70^. When disturbed he became very fierce and active, shrieking and
Inting the bars of his cage; and at 9h. 40m., his temperature was 92°. Soon aAer this he
became quiet again, and at lOh. 30m. his temperature was 80°. The temperature of the
atmoaphere daring these examinations had gradually increased from 61° to 67°. — April
30th, at 8 AJi., he was feeble, but not torpid : the temperature of the room during the night
had been between 40° and 45°, and was now 57° ; the temperature of the bat was only
59°. At 1 1 iuM., after struggling violently for half an hour, it rose to 69°. After being long
nnder chloroform, and nearly dying, he remained all the afternoon only one or two degrees
warmer than the atmosphere. But at night, at 12b. I5m., he recovered and became active ;
and, while the atmosphere was at 65° he was at 85°. At 12h. 40m., after being made very
paiKOKKHA or IRTLAMKATIOir:
llie remarkable condition, discovered by Mr. Wharton Jone*,'
those veins in the wing that have valves contract vfith regular rh^ln
for the acceleration of the venous stream, may effect in some meMnrr
the morbid aa well as the normal movement of the blood. Still, mn
in the development of their nervous system, and tho cummensantc
developmont of their heart and respiratory organs, and in the cIoh
reciprocal relations in which these act, the bats resemble the otlur
warm-blooded vertebrata, ne may, I think, fairly assume a close ream-
blance also in their processes and conditions of nutrition.
The simplest effects upon the bloodvessels are produced by a tl^
mechanical stimulus. If, as one is watching the movement of blood la t
companion artery and vein, the point of a 6ne needle bo drawn aoM
them three or four times, without apparently injuring them or the mM-
brane over them, they will both presently gradually contract and fImc
Then, after holding themselves in the contracted state for a fewminutt^
they will begin again to open, and, gradually dilating, will acqvire i
larger size than they had before the stimulus was applied-t
Simple as this observation is, it involves some cardinal facta U OIT
pathology. It illustrates first, the contractile power of both arum
and veins; it shows that this is possessed by the smallest, jnst uil a
by the larger, vessels of both kinds ; and by the manner of their est-
traction, which follows at some interval after the application of d«
stimulus, and is slowly accomplished, it shows thut their power of «B-
traction is like that of parts with smooth or organic muscular fibra.
But, again, the experiment shows the vessels reopening and beevn-
ing wider than they were before ; either yielding more to the pfMnit
of the blood which previously they resisted with more strength, or dH
BclcF, he wuBi SS°; BnJ u lli. 30m. remained at 8a°. N'eii mMning he WM tit'
acareelj wann«r itian Llie almnepliere. The leiDperalura wmb alwiy* iak*n wilblMd
(liermonirlet applied to ihf tuttaix of tlie Bbdomen.
■ Philo* Trani., ISS'i, Pari I.
t Some doubl hai been expreueil a* lo lh« coiilnction of Ihe veins here doclibal.t'
Mr. Wlurlon lone* bat not been able u> convince himtejf of iL tie contiilers, alaoi lW<*
ihe I>ob'i web the veins nie capable of bul iligbi rnriaEion in dlamelrr ibnnifli lb* op*'
tioo »f Rnitraclili* power ; and lliig acoord* with E. H. Webet'i obseiTatiuns (MQllM*! t*
obiv, 1S4T], Leben, on Ihe nlbei hind, eiprculf Myi IbaT he bat obieived the ma»l^
polou relalive lo Ihe oondiiion of ibe blood veiaeli, and ihe moTement of die blood ia 6^
my obMmiiiiini accord wilh Ibow which Mt. Wbanoo Jone* hid compleied, byl iMp^
lisht^, when Ihe leclurei were delivered. The reader miiy, hriwerer, find in bu adoi*
ablr etaay (Guy '« Ho«plml Reporli, I8»l), many miimle delaili which 1 bad DM lNi«*l
■Dd many lllumatiani of «in)|ular beamy and accuracy.
Mr. Lisler (Phil. Tran*., ISSS, p. 6!>a) hoi obMrved a conayerable deittee of hMlM»
tiaclion on one oroaiion in ihe vein of a frog'i web, ahUough uenerally they do nonlW*
gn«l oontrmriile propetliei. and in man and >ome of the h'lghat animalihc bai tioiiool "f*
ral itrikinB example* of the eoniraeillity of tbe Intger «ein>. In the tamp jiatwr, p. Ul<
and InTtani Rny. Sue. Fjlin.. vol. ixi, p. -Mil. he hai carefully d««crib«d llie arran|«a»al of
ihe milaculai nbreocllg in the walli of Ihe small arleriea. Le/dig again (Arobi* f Aml
and Phyi. I8S0) haa aiatsd that ihc muacalar Hbret of the voin)«flh» wlngof ibabUM'
hibii evidence! of iiaoiveiia airiaiioD.
STATE OF THE BLOODVESSELS. 215
dilating, as of their own force, with that which Mr. Hunter called active
dilatation, and compared with the act of dilatation of the os uteri. In
whichever way the dilatation is eflfected, whether it be active or passive,
the vessels will not at once contract again under the same stimulus as
before affected them. The needle may be now drawn across them much
oftener and more forcibly, but no contraction ensues, or only a trivial
one, which is quickly succeeded by dilatation. Yet with a stronger
stimulus, such as that of great heat, they will again contract and close.
And such a contraction excited by a cautery may last more than a day,
before the vessels again open and permit the flow of the blood through
them.
Moreover, we may observe in this experiment the adapted movement
of the blood. As the vessels are contracting the blood flows in them more
slowly, or begins to oscillate ; nay, sometimes, I think even before the ves-
sels begin visibly to contract, one may observe that the blood moves more
slowly in them, as if this were an earlier effect of the stimulus : nor have
I ever seen (what has been commonly described) the acceleration of the
flow of blood in the contracting vessels. Such an acceleration, how-
ever, is manifest, as the vessels reopen ; and as they dilate, so, appa-
rently in the same proportion, does the flow of blood through them become
more free, till, at length, it is manifest that they are traversed by both
fuller and more rapid streams than passed through them before the
stimulus was applied. How long this state may last depends on many
circumstances hard to estimate ; but at length it ceases, and the vessels,
and the circulation through them, assume again their average or normal
state.
Such are the effects of the mechanical stimulus of bloodvessels.
The effects of other stimuli applied to the wings of bats correspond
in kind, but differ in degree and extent. If a drop of acetic acid, of
tincture of capsicum, of turpentine, or of ethereal solution of cantha-
rides, be placed on a portion of the wing, or washed over it, one sees a
quickly ensuing dilatation of the bloodvessels, and a rapid flow of blood
through them all. I am not sure that the dilatation is preceded by con-
traction. Certainly the contraction is very slight, if it occur at all ;
but the dilatation is usually much more extensive. When the stimulus
has been applied to only one small spot upon the wing, the whole of the
bloodvessels in the corresponding metacarpal space, and even those of
the adjacent spaces, may enlarge. One might imagine that the dilata-
tion of vessels was due to an increased action of the heart, if it were
not that (as I think) it is always greater at the very point to which the
stimulus was applied than in any other part of the same wing, and is
never at all imitated in the corresponding parts of the opposite wing.
The state which is thus induced by stimuli is what is commonly under-
stood by the expressions '^ active congestion;*' or '^ determination of
blood," in a part. It consists, briefly, in general enlargement of the
bloodvessels of the part, with an increased velocity of the blood in them.
216 PHENOMBNA OF INFLAMMATION:
It is, probably, just such a state as this that is felt by suckling women
in what they term the ^^ flow of milk." It seems to be an increased
flow of blood in the mammary gland just before a quicker secretion of
the milk. Less normally, it is such a state as this that we observe in
the skin after the application of mustard, or sharp friction, or a heat
from 20^ to 50^ above its own, or in the most striking instance, when a
drop of strongest nitric acid is placed on the skin, and, in a few seconds,
all the surrounding area seems to flush, and feels burning hot. Such,
too, we may suppose to be the state of the vessels of the conjunctiva,
when stimulated by dust that is soon dislodged ; and such the condition
of many internal organs, when we might tloubt whether they are in-
flamed, or are only very actively discharging their natural functions.
Herein, indeed, in what I have described is one of the pieces of neutral
ground between health and disease : a step in one direction may effect
the return to health ; in another the transit to what all might admit to
be the disease of inflammation.
Now, this transit appears to be made when the circulation, which was
rapid, begins to grow slower, without any diminution, but it may be
with an increase of the size of the vessels. This change one may see
in the bat's wing. After the application of such stimuli as I have al-
ready mentioned, the movement of the blood may become gradually
slower, till in some vessels, it is completely stagnant. The stagnation
commences, according to Mr. Wharton Jones, in the capillaries ; and
first in those which are least in the direct course from the artery to
the vein (in the stimulated frog's web): thence it extends to the veins
and to the arteries.
A corresponding state of retardation of blood, leading to partial stag-
nation of it, may be well seen after such an injury as that of a fine red-
hot needle driven into or through the membrane of the wing.
The first effect of such an injury (in addition to the charring and
searing of the membrane, the obliteration of its bloodvessels, and the
puckering of the portion of it adjacent to the burn) is to produce con-
traction of the immediately adjacent arteries and veins. They may
remain closed, or, as I have already described, after being long closed,
may again open, and become wider than they were before. This dilata-
tion follows more certainly, and perhaps without any previous contrac-
tion, in the arteries and veins at a little distance from the burn. In
these, there speedily ensues such a state of " determination of blood"
as I have already described : in arteries and veins alike the stream is
full and rapid; and the greater accumulation, as well as the closer
crowding, of the red corpuscles, makes the vessels appear very deep-
colored. The contrast of two diagrams, showing the natural and the
stimulated conditions in a single segment of the vascular plan of the
wing, illustrates this difference sufficiently well* (Figs. 80 and 81).
* The plan of vessels drawn is copied from a portion of Mr. Wharfoa Jooea't plats.
Philos. Trans. 1852, part 1, plate v.
flTATB OF THE CIR CPL ATIOH.
The Tessela of the one, nearly tvice as large as those of the other,
du-ker, uid more turgid with blood ; and, in the one, numeroue capil-
lariee which are not visible in the other. But diagrams cannot show
the changes in the mode of movement. Close by the burn, the blood
which has been flowing rapidly begins to more more slowly, or with an
Fig. 81.
I meertain stream ; stopping, or sometimes ebbing, and then again flow-
' iogon, but, on the whole, becoming gradually slower. Thus it may, at
Jeogth, become completely stagnant ; and then, in the vesBels in which
218 PHENOMENA OF INFLAMMATION:
it is at rest, it seems to diffuse and change its color, so that its crowded
corpuscles give the vessels a brilliant carmine appearance, by which,
just as well as by the stillness of the blood, they may always be dis-
tinguished. As one surveys an area surrounding this part, one sees
streams the more rapid the more distant they are &om the focus of the
inflammation. And often, when there is stagnation in a considerable
artery, one may see the blood above or behind it pulsating with every
action of the heart, driven up to the seat of stagnation, and thence car-
ried off by the collateral branches ; while, in the corresponding vein, it
may oscillate less regularly, delaying till an accumulated force propels
it forward, and, as it were, flushes the channel.* In the area still more
distant, one sees the full and rapid and more numerous streams of " de-
termination" or " active congestion," which extend over a space alto-
gether uncertain.
Such is the general condition of the circulation in and around a part
that is inflamed. In a few words, there is, in the focus of severe in-
flammation, more or less of stagnation of blood ; in and close around it,
there is congestion^ — i, e, fulness and slow movement of blood ; more
distantly around there is determinatum^ — i. e, fulness and rapid move-
ment of blood. The varieties in lesser points that may be presented
cannot be described. These must be seen ; and, indeed, the whole
sight should be viewed by every one who would have in his mind^s eye
a distinct image of what, in practice, he must often too obscurely con-
template.
The phenomena that I have described as seen in the bat's wing cor-
respond very closely with those observed in the frog's web. Only, I
think the stagnation of blood is neither so constant nor so extensive in
the bat : it is seen in portions of single vessels, rather than in districts
of vessels ; often in corresponding portions of arteries and veins, as they
lie side by side. The stagnation usually extends into such branches as
may be given from the vessels that are its principal seats ; and three or
four such seats of stagnation may appear placed irregularly about the
burn, or other focus of the inflammation ; but I have never seen a ge-
neral stagnation of blood in all the vessels of even a severely stimulated
part. My impression is, that, in strong and active warm-blooded ani-
mals, stagnation of Blood would be found in only the most severely in-
flamed parts : in others, I think, retardation alone would exist.
To sum up now what concerns the supply of blood in an inflamed
part. We seem to have sufficient evidence that, in general, in the focus
of the inflammation, blood is present in very large quantity, distending
all the vessels, gorging them especially with red corpuscles, but often,
moving through them slowly, or even being in some of them quite stag-^
nant ; that all around this focus, the vessels are as full, or nearly 2l&
* What I thus described was, no doubt, the result of the rhythmical contraction of th.<?
veins, which Mr. Wharton Jones has since discovered.
STATE OF THE CIRCULATION. 219
full, as thej are in it, but the blood moves in them with a quicker
stream, or may pulsate in the arteries, and oscillate in the veins; that,
yet farther from the focus, the blood moves rapidly through full but
less turgid vessels. And this rapidity and fulness are not to be as-
cribed, I think, merely to the blood, which should have gone through
the inflamed part, being driven through collateral channels, but are
such a state as is commonly understood as an '^ active congestion," or
^^determination of blood" in the part.*
I have already said, that we may believe that what is seen in the bat
represents fairly the state of inflamed parts in all warm-blooded ani-
' mals. I am quite conscious that the most one can see with the micro-
scope, in these experimental inflammations, is but a faint picture of
such inflammations as we have to consider in practice ; that it is very
trivial in both its appearance and its results. Still, it is a picture of a
disease of the same kind ; and a miniature, even faintly drawn, may be
a true likeness. Besides, all that can be observed of the complete pro-
cess of inflammation in man is consistent with what we can see in these
lower and lesser creatures. The bright redness of an inflamed part
testifies to the fulness of its bloodvessels, and the crowding of the cor-
puscles ; the occasional duskiness or lividity of the focus is character-
istic of stagnation ; the throbbing in the part, and about it, and the full
hard pulse in the ministrant arteries, are sure signs of obstruction to
the passage of blood ; the gush of blood on cutting into the tissues near
an inflamed part, or in bleeding from one of their veins, tells of the de-
termination of blood in these, and of the tension in which all the con-
taining bloodvessels are held.
It is particularly to be observed that the stagnant or retarded blood
is not apt to coagulate. I have found it fluid after at least three days'
complete stagnation, and so I believe it would remain till it is cleared
away, unless the part sloughs. In the latter case it would coagulate,
as it does in carbuncles and the like, which hardly bleed when we cut
them through ; but, so long as the blood is fluid, though stagnant, it
may be driven from the vessels with full force, as soon as an easy exit
for it is made by cutting into the inflamed part, or opening one of its
Urge veins. I need only here refer to Mr. Lawrence's well-known and
instructive experiment. In a patient with an inflamed hand he made
similar openings into veins in both arms. From the vein on the diseased
side three times more blood flowed than from the vein in the healthy
* Professor Lister (Phil. Trans., 1858, p. 658), aAer a careful inquiry into the effects of
ititants apon the circulation, has clearly pointed out that we ought to make a distinction be-
aten that dilatation of the arteries, which induces determination of blood to a part, and
^ accumulation of corpuscles in the capillaries, which causes inflammatory congestion.
The two processes differ in their nature, and are produced by independent causes. The
ftttis due to a relaxation of the muscular fibres of the arterial coats, developed through the
iBcdioni of the nervous system, whilst the second is the result of the direct action of the
'ititut apon the tissues, and a consequent change in the quality of the blood in their
»icimty.
220 PHENOMENA OF INFLAMMATION:
arm, in the same time. This increased flow represented at once the
greater determination of blood about the focus of the inflammation, and
the greater tension in which the walls of the bloodvessels, and, indeed,
all the tissues of the inflamed and swollen part, were held.
Now, to what can we describe these changes in the movement of the
blood ?
It has been commonly said that, as the vessels contract, therefore the
movement of blood becomes more rapid in them, as when a river enter-
ing a narrow course moves through it with a faster stream ; and that
then, as the vessels widen, so the stream becomes, in the same propor-
tion, slower. But this is far from true. The stream becomes slower
as the artery or vein becomes narrower by contraction; and then, as
the tube again dilates, the stream grows faster ; and then, without any
appreciable change of size, it may become slower again, till complete
stagnation ensues in at least some part of the bloodvessel.* I think I
can be quite sure that the velocity of the stream, in any vessel of an in-
flamed part, is not wholly determined either by the diminution or enlarge-
ment of the channel, or by the stagnation or congestion of blood in the
vessels beyond. That much of the change in rate of movement depends
on these conditions cannot be doubted ; and it may seem unnecessary to
question their suflSciency for the explanation of that change, after Mr.
Wharton Jones's observations. But I think other forces must still be
considered, whose disturbance may contribute to the result. Whether
we name it vital afiinity, or by any other terms, or (which may, a^ yet,
be better) leave it unnamed, I cannot but believe there is some mutual
relation between the blood and its vessels, and the tissues, or other sub-
stances around them, which, being natural, permits the most easy transit
of the blood, but, being disturbed, increases the hinderances to its pas-
sage. Such hinderances appear to be produced by the addition of salts
of baryta, or of potash, to the blood ; and by an excess of carbonic acid
in the blood that should traverse the minute pulmonary vessels. The
presence of an excess of urea in the blood probably produces the like
effect : and some of the facts connected with other than traumatic in-
flammations appear quite inexplicable without such an hypothesis as
this.f
II. I mentioned, as the second condition necessary to the healthy
nutrition of a part, a right state and composition of the blood. In for-
mer lectures (p. 34, et seq.) I pointed out that, by this state, we must
understand not merely such purity of the blood that chemistry cannot
* As Mr. Wharton Jones has shown, the retarded stream exists only when the vessel is
generally contracted, and the accelerated stream when it is generally dilated : when a single
vessel presents successive enlargements and diminutions of calibre, the rate of the stream in
it diminishes in the former and increases in the latter.
t Since the publication of the first edition of this work, the correctness of the view ex-
pressed in the text has been fully confirmed by the observations of Mr. Lister, who has shown
that when the tissues are unhealthy, the bloo<l which flows near them acquires properties
tliat render it unfit for transmission through the minute vessels. See note to page 223.
STATE OF THE BLOOD. 221
detect a wrong constituent in it, or a wrong quantity of any of the ab-
normal ones, but that natural constitution of the blood by which it is
exactly adapted to every tissue that it has to nourish ; with an adapta-^
tion so exact that chemistry often cannot approach to the determination
of whether it is maintained or lost.
That this adaptation is disturbed, in many cases of inflammation, is
proved by the instances to which I shall have to refer, in which they
plainly have their origin in morbid conditions of the blood. But I fear
that the nature of this disturbance cannot yet be chemically expressed,
and the facts which chemistry has discerned, in the condition of the
blood in inflammations, cannot yet be safely applied in explanation of
the local process. For, first, we observe the phenomena of inflamma-
tion where we cannot suppose the whole blood disordered ; as after the
application of a minute local stimulus, such as a foreign body on the con-
junctiva: secondly, th^ changes observed in the blood during inflamma-
tions are not peculiar to that state, but are found more or less marked
in pregnancy, and in other conditions in which no inflammatory process
exists ; and, thirdly, among the changes observed in inflammatory
blood, the principal one, namely, the supposed increase of fibrine, is
ambiguous ; it may be at once an increase of fibrine and of the white
corpuscles of the blood. These two constituents of blood, the fibrine
and the white or rudimental corpuscles, cannot ^be well separated by any
process yet invented ; and in all the estimates of fibrine, whether in
health or in disease, the weight of the white corpuscles is included.
Now, in many inflammations these corpuscles are increased ; and in such
cases we have no means of clearly ascertaining how much of an appa-
rent increase of fibrine is really such, and how much is due to the cor-
puscles entangled in the fibrine. Till this can be settled, I think we
may not deduce any of the local phenomena of inflammation from the
increase of fibrine in the blood ; neither, more assuredly, can we trace,
as some do, the fever and other general signs of inflammation to the
abstraction of fibrine and albumen by the exudation from the blood.
The other principal changes of the blood in inflammation — the dimi-
nution of its red corpuscles and increase of water — are even less adapted
to explain any of the phenomena of the local process. Whatever may
be their strength or value as facts, they are as yet isolated facts, such
as we cannot weave into the pathology of the disease.
I fear, too, that the structural condition of the blood will not, more
than the chemical, help us to explain the phenomena of inflammation.
Some of our most worthily distinguished pathologists have ascribed
much to the existence of large numbers pf the white blood-corpuscles,
and their accumulation in the vessels of the inflamed parts ; indeed,
they have taken this for the foundation of nearly their whole doctrine
of inflammation, ascribing to it both the stagnation of the blood and
the changes it is presumed to undergo ; such as the increase of the
fibrine, and many others. But the statements on which they have
222 PHENOMENA OF INFLAMMATION:
rested are unsound : their observations have been made on frogs, and
do not admit of application to our own case, or, perhaps, to that of any
.warm-blooded animal.
In many frogs, especially in those that are young, or sickly, or ill-
fed, the white corpuscles are abundant in the blood. They are rudi-
mental blood-cells, such as may have been formed in the lymph or chyle;
and in these cases they are probably either increasing quickly in adap-
tation to quick growth, or else relatively increasing because, through
disease or defective nutriment, although their production is not hin-
dered, yet their development into the perfect red blood-cells cannot
take place. But I believe nothing of the kind happens in older or more
healthy frogs, or in any ordinary inflammation in the warm-blooded
animals. I have drawn blood from the vessels in the inflamed bat's
wing, in which it was quite stagnant, and have found not more than
one white corpuscle to 5000 red ones. I have often examined the
human blood in the vessels of inflamed parts after death, and have
found no more white corpuscles in them than in those of other parts.
In blood drawn from inflamed parts during life, I have found only the
same proportion of white corpuscles as in blood from the healthy parts
of the same person. I therefore cannot but accord with the opinion,
often expressed by Mr. Wharton Jones and Dr. Hughes Bennett, that
an especial abundance of white corpuscles, in the vessels of an inflamed
part, is neither a constant nor even a frequent occurrence ; and I be-
lieve that, when such corpuscles are numerous in an inflamed part, it is
only when they arc abundant in the whole mass of the blood.* Now,
as already itated, they are thus abundant in some cases of inflamma-
tion ; especially, I think, in those occurring in people that are in weak
health, and in the tuberculous ; but, even in these cases, I have never
seen an instan<5e in which they were present in sufficient quantity to
add materially to the obstruction of the blood in the inflamed part, nor
one in which any influence of theirs could be suspected to alter pecu-
liarly the constitution of the blood therein.
It has long been known that when healthy blood is received on a
glass plate, and immediately examined with the microscope, the cor-
puscles may be seen in about half a minute to run together into piles,
or rouleaux, which arrange themselves in a small meshed network, as
in the adjoining figure (a), (Fig. 32). Mr. Wharton Jones was the first
to point out that if a drop of blood of a patient suffering from acute
rheumatism, or inflammation, be similarly examined, the piles of cor-
puscles are formed more rapidly and run more closely into masses, which
have large spaces between them (b). By this arrangement the thin
clot, outspread on the glass, has the peculiar mottled pink and white
appearance which Mr. Hunter observed as one of the characters of in-
* Dr. Hughes Bennett's researches on Leucocythapmia have shown that even the ez-
treraest abundance of white corpuscles in the blood has no tendency either to produce or to
aggravate inflammations.
8TATB OF TH
flAmmatory blood. The same condition is observed in the blood of
pregnant women, and appears natural in that of borsea ; and in all these
cases it ma; be regarded as the chief cause of the formation of the bufiy
Fig. 82.
coat, inasmuch as the clustered blood-cells, sinking rapidly, generally
Bobaide to some distance belon the surface of the liquid part of the
blood, before the coagulation of the fibrine is begun. This aggrega-
tion of the corpuscles does not appear to be duo, as was at one time
Bnpposed, to an increased viscidity of the liquor sanguinis owing to an
excess of fibrine, for Lister's observations have shown that they aggre-
gate quite as closely after the removal of the fibrine, as they did before.
Some have supposed that a similar adhesion of the blood-cells may
occur in the vessels of an infiamed part, and produce or materially affect
the inflammatory process. I have seen nothing of the kind in either
the inflamed bat's wing or in the vessels of inflamed organs examined
after death. When the blood is not stagnant the corpuscles are indeed
closely crowded, but they are not clustered, nor do they appear adhe-
rent ; neither does such clustering appear even in stagnant blood ; the
change here appears to be a diS'uHJon of the coloring matter, so that the
oatlines of individual blood-cells cannot be seen, and all the contents of
the vessel present a uniform bright carmine tint.*
* Tht adhesion oT the corpuKles or llie blooil to each olhei, anit u> Ihe inner surrace of
die walls of the vesKis of an Inflamed part, has of laic engageil the altentlon of iiathnla-
pau. Mr. Lislei has especially inveaTigaied ihis subjeci.and has reached several very im-
pCTtsnt concliuions. In Iha vesacls of a heallhy pan neilher die red ror while odtpiiscles
exhibii anf leiulency (o adhesiveness. When die pan is irritated ui inllnmed, both kinda
irf corpuscles acquire siKh a degree of adhesiveness as makes ibem slick to each other and
lo (he walla of the vesseU, and it is through this Ihat Ihe stasis, or " sUKiation of blood" in
the inn, is occasioned. Mr. Lisler, however, believes Ibat the amonnt ofmlhesion in Ihesa
cases is never grealei than that whicb is exhibited by the corpuscles taken from a healthy
pmn when eismined outside the body, as on a plaie of glass. So lonp therefore as the
Mood flow* IhrODgh Ihe lesaels of a healthy pari, no adhesion of Ihe corpuscles, either to
taeh other or to the watU of ihe vessels, takes place. But when, through the applicatioa
224 PHENOMENA OF INFLAMMATION:
But although we can see so little of the changes that may ensue in
blood thus stagniant or much retarded, yet we may be nearly sure that
the blood in an inflamed part does undergo important changes, when we
remember what general effects, what constitutional disturbance, may
ensue in the train of an inflammation of purely local origin. Changes
probably ensue in the blood similar to some of those that we shall have
to trace in the lymph effused from it into the parts around the vessels ;
particles of fibrine may coagulate* in it, and corpuscles like those of
lymph may be formed and degenerate within it ; and these, when the
stagnation is not constant, or is incomplete, or is passed away, may be
carried into the general circulation, infecting the whole blood, exciting
general disturbance, as in traumatic fever, or producing various and
wide-extended suppurations, as in the purulent diathesis following local
injury. All these, and many other concomitants of inflammation, may
be reasonably ascribed, at least in part, to the changes that the blooa
undergoes in the inflamed tissue ; but I must repeat that nothing that
either the microscope or chemistry has yet discerned will suffice to ex-
plain these changes ; they belong riather to the theory than to the facts
of inflammation.
III. The third enumerated condition for the healthy nutrition of a
part is a certain influence of the nervous force. The change that this
undergoes in an inflamed part is, therefore, next to be considered ; or,
rather, the evidence that it is changed is to be cited ; for, as we have no
exact knowledge of the manner in which the nervous force operates in
ordinary nutrition, so neither can we tell how its operation is affected
in inflammation, though we may be sure that it is not normal.
The expression that the nerves of an inflamed part are in an " excited
state,*' is suggested by the existence of pain ; by a slight stimulus being
acutely felt ; by the natural heat, or a slight increase of the heat, being
felt as a burning ; and by the part being, even independent of any
known stimulus, the seat or source of subjective pains and heat. But
the very frequent cases in which pain exists, and abides long, without
any other sign of inflammation, and the cases in which the pain bears
no kind of proportion to those other signs, or to the effects of inflam-
mation,— these may suggest that, besides this "excited'* state of the
nervous force, which is felt as pain in the inflamed part, there may be
of an irritant, the healthy state of the tissues is changed, then they assume towards the
bloo<l the relation of dead or inorganic matter, upon which adhesiveness of the corpuscles
occurs, and inflammatory congestion is occasioned.
Many recent experiments on the frog's web (H. Weber, MQller*s Archiv, 1853), (Scbuler,
Wurzburg Verhandl. B. iv, H. iii) ; (Gunning, pamphlet, Utrecht, 1857); (Lister. Phil.
Trans., 1858), made, either after tightly applying a ligature around the limb, or even after
amputation, show that accumulation of corpuscles may be produced in a part even when
cut off partially, or entirely, from the rest of the body, by the application of the various irri-
tants which produce it in the perfect limb. Inflammatory congestion is, therefore, quite in-
dependent of the general circulation.
STATE OF THE NERVE-FORCE. 225
some other state by which the nervous force is more intimately con-
nected with the inflammatory process ; a state of disturbance which
may, indeed, be felt as pain, but which more properly affects the influ-
ence of the nervous force in the process of nutrition.
We obtain some evidence of the existence of such a state in the fact,
that, without relation to pain, it is communicable from the nerves of in-
flamed parts to those of other parts ; in which parts, then, a kind of
sympathetic inflammation may be generated. This transference or com-
munication of the disturbance of nervous force is, indeed, evident enough
in relation to that state which is felt as pain ; for pain is not limited to
the inflamed part, but is difi'used around it, and is, in sympathy, often
felt where no other sign of inflammation exists. But, besides, and some-
times, I repeat, independent of this condition which is felt as pain, the
inflammatory condition, if I may so name it, of the nervous force, may
\)e similarly communicated or transferred. The simplest may be the
most proving instances. Whoever has worked much with microscopes
may have been conscious of some amount of inflammation of the con-
junctiva, in consequence of overwork. Now, the stimulus exciting this
inflammation has been directly applied to the retina alone ; and I have
often had a slightly inflamed left conjunctiva, after long working with
the right eye, while the left eye has been all the time closed. I know
not how such an inflammation of the conjunctiva can be explained, ex-
cept on the supposition that the excited state of the optic nerve is trans-
ferred or communicated to the filaments of the nerves of the conjunctiva,
generating in them such a state as interferes with its nutrition. It is
true that, in these simpler cases, the retina is not itself evidently in-
flamed ; but after yet severer stimulus it commonly is so, and the con-
junctiva shares in the evil effects of the communicated stimulus ; effects
which we cannot ascribe to any alteration in the blood, or the size of
the bloodvessels.
I may mention another case ; the occurrence of inflammation of the
testicle in cases of severe irritation of the urethra. The most unexcep-
tionable cases of the kind are those in which the irritation is produced
hy a calculus impacted in a healthy urethra. I have a specimen, "*" in
which extensive deposits of lymph and pus are seen in the testicle of a
man, in whose urethra a portion of calculus was impacted after lithotrity.
Here is such an inflammation as we cannot refer to disease of the blood,
and attended by such changes as we cannot explain by any enlargement
or paralysis of the bloodvessels : nor do I know how it can be at all ex-
plained, except by the disturbance of the exercise of the nervous force
in the testicle, which disturbance was excited by transference from the
morbidly affected nerves of the primary seat of irritation in the urethra.
In like manner, I believe that the extension or transference of in-
lammation, after or with pain, may be ascribed, at least in part, to the
* Museum of St. Bartholomew's Hospital, Ser. xxviii, No. 55.
226 PHENOMENA OF INFLAMMATION.
coincident transference of the disturbed plasturgic force of the nervous
system. In paroxysms of neuralgia, we see sometimes a transient in-
flammatory redness or oedema of the part ; so, when a more abiding
pain has been excited, by sympathy with some inflamed part, there may
presently supervene the more palpable effects of inflammation.'*'
I feel that in discussing such a point as this, one passes from the
ground of demonstrable facts ; but there is, I hope, less fault in this than
in the belief that the very little we can see of a morbid process can
guide us to its whole pathology. When we look at an inflamed part, we
should not think that, if we could see its bloodvessels and test its blood,
we should detect all that is in error there : rather, we should think that
all the forces are at fault which should be concurring to the due main-
tenance of that part ; and while we are ignorant of the nature of some
of these forces, it is better that their places in our minds should be oc-
cupied by reasonable hypotheses, than that they should be left blank,
or be overspread with the tinge of one exaggerated theory, such as those
are which ascribe all inflammation to a change in some one of the con-
ditions of nutrition.
IV. The last condition necessary to healthy nutrition in a part is the
natural or healthy state of the part itself.
The manner in which this is changed in the inflammatory state can-
not be well considered till an account has been given of the exudation
that takes place from the bloodvessels, and of some other changes in the
very process of nutrition. Let it, for the present, suffice to say (1),
that a change in the condition of a part involving a disturbance in the
nutrition of the proper textural elements, may be the cause, indepen-
dently of bloodvessels or nerves, of an inflammation in it, as in wounds,
lodgement of foreign bodies, and other injuries of non- vascular and
other parts ; and (2) that when an inflammation is thus, or in any other
way, established, the proper elements of the affected part continually
suffer change.. Such changes are due, first, to the degenerations which,
as in other cases of hindered nutrition, the elemental structures spon-
taneously undergo : and, secondly, to the penetration of the inflamma-
tory product into them and the interstices between them. Each of
these sources of change may, in different cases, predominate : in cer-
tain cases, it is probable that one alone of them may be effective ; and
either or both of them may affect either the elemental structures that
are already perfected, or, probably, in a greater degree, the materials
that are in progress of development, f
* In the second lecture the effects produced upon the nutrition of a part by the division or
irritation of the nerves going to it, has been discussed.
f At this place it may not be amiss to advert to the very striking experiments of Mr.
Lister (Phil. Trans. 1858), on the influence exercised by irritants on the pigment cells in
the frog's web and on the movements of the cilia, which indicate that an impairment in the
functional activity of the tissues is the essential occurrence which leads to inflammatory
stasis of the blood. For it appears that all Agents capable of causing inflamraatory oonge»'
PRODUCTS OF INFLAMMATION. 227
All these things will be subjects of future lectures ; but, before pro-
ceeding to them, let me add a few words, to prevent misunderstanding.
I have spoken so separately of the changes in the several conditions
of nutrition, that I may have seemed to imply that inflammation may
consist in the disturbance sometimes of one, sometimes of another, of
these states. It is true that inflammation may have its beginning in
any one of these conditions. Indeed there is not one of them that has
not been made the cause of inflammation by some one who has looked
at the subject from too narrow a point of view, — as in an alteration of
the blood in rheumatism, in an alteration of the nervous force in irri-
tation of the retina, in an alteration of the proper elements of the tissue
in inflammation of the cornea ; but, probably, it is never fully estab-
lished without involving in error all the conditions of nutrition ; and
both the manner in which they may be thus all involved, and their sub-
sequent changes, should be studied as concurrent events, rather than
as a aeries of events, of which each stands in the relation of a conse-
quence to one or more of those that preceded it. Nowhere more than
here is the mischief evident, of trying to discern in the economy of or-
ganic beings a single chain or series of events, among which each may
appear as the consequence of its immediate predecessor : most fallacious"
is the supposition that, starting from a turgescence and stagnation of
blood in the vessels of a part, we may explain the pain, the swelling,
the heat, and all the other early and consecutive phenomena of inflam-
mation. The only secure mode of apprehending the truth in this, as
in every other part of the economy of living beings, is by studying what
we can observe as concurrent, yet often independent, phenomena, or as
eyents that follow in a constant, but not necessarily a consequent, order.
LECTURE XIV.
PRODUCTS OF INFLAMMATION.
The state described in the last lecture may, without further change,
cease and pass by, and leave the part, apparently, just as it was before.
^ when applied to a vascular part, produce, by tbeir direct action upon the tissues, a state
<inite distinct from death, in which, nevertheless, the powers of the tissues are completely
piQstnted for the time being, and that a greater or less degree of this temporary loss of
power invariably occurs as a primary effect of irritation if carried sufficiently far to induce
•oy inflammatory congestion. If the action of the irritant is not too powerful, or if its ap-
plication is not too prolonged, then the derangement in the functions of the textures is gradu-
ally restored, along with, and apparently as a consequence of^ which restoration, the vascu-
lar congestion terminates, and the blood flows along its vessels in the usual manner. These
^rvations on the state of the tissues are in complete harmony with those made by the
^ne autbor upon the blood corpuscles, which, as stated in the note to p. 223, appear to
*^iiire adhesiveness in an irritated part in consequence of the affected tissues ceasing to
^Bviataiii their normal vital.relations to the blood.
228 PRODUCTS OF INFLAMMATION:
And there are two chief modes in which this may happen ; namely,
by resolution or the simple cessation of the inflammation, and by me-
tastasis, in which, while the inflammation disappears from one part, it
appears in another. So far as the inflamed part itself is concerned, I
believe the changes are in both these cases the same, and consist in a
more or less speedy return to the normal method of circulation, and
the normal apparent condition of the blood and of the nerves ; the tis-
sue itself presenting no change of structure.
I do not know that any description of the process of recovery, from
the inflammatory state, would tell more than is implied by calling it a
gradual return to the natural state, a gradual retracing of the steps by
which the natural actions had been departed from. As it has been
watched in the frog's web, and in the bat*s wing, the vessels, that were
filled with quick-flowing blood, become narrower, the streams in them
also becoming slower, and less gorged with red blood-corpuscles, till the
natural state is restored. The pulsating or slower streams are equal-
ized with those about them, and, gradually making their way into the
stagnant columns, drive them on or disperse them. In the frog, clus-
ters of blood-corpuscles have been seen to become detached, by a
stream breaking ofi" portions of the stagnant blood, and then to float
into the current, where, gradually, they disperse. So, too, in the tad-
pole, after injury, I have seen fragments of fibrine, washed from the
blood in the vessels of the injured part, floating in some distant vessels.
Virchow's and Kirkes's observations leave no doubt that similar changes
may occur in the warm-blooded animals, and may be the source of great
evil by carrying the materials of diseased or degenerate blood from a
diseased organ to one that was previously healthy (p. 116).
It may be difficult to explain this recovery in the case of complicated
inflammations. When a slight mechanical stimulus has been applied,
and the vessels, after contracting, have dilated, we may see some signs
of weakened muscular power, in the fact that the same stimulus will
not make them contract again ; and then their gradual recovery may
be the consequence of their regaining their weakened and exhausted
power, just as a wearied muscle does when left at rest. This must
always be one element in the recovery of the natural state, by a part
that has been inflamed ; indeed, it is probably that part of recovery
which is most slowly achieved. Still, it is, probably, only one ele-
ment in the process of recovery. In an inflammation in which all the
conditions of nutrition are at fault, each must recover its normal state ;
but, of the manner in which they severally do so, we have no know-
ledge. The order in which they are restored is scarcely less uncertain ;
probably it is not constant, but may depend, in great measure, on the
order in which they were involved in error. But we have no clear
facts in this matter ; only we may observe, that in many cases, if we
correct the error of one of the conditions of nutrition, the rest will be
more apt to correct themselves. Thus, of the remedies for inflamma-
SERUM. 229
tion, few can act npon more than one of the conditions on which it de-
pends ; yet they may be remedies for the whole disease ; for, as it were,
by abstracting one of its elements, they destroy the consistence and
mutual tenure of the rest.
The cessation of the disease may be regarded as the most perfect
cure of which inflammation admits. It is in many cases an unalloyed
advantage ; but in some it is not so, though the local change may be
the same ; for materials accumulated in the stagnant blood of the in-
flamed part, or absorbed from its morbidly altered tissues, may, when
the inflammation subsides, pass into the general current of the blood,
and infect its whole mass, or disturb the nutrition of an organ more im-
portant than that which they have left. Such are the events of the
metastasis of gout, and the premature subsidence of cutaneous erup-
tions.
We have now considered how, in the inflammatory state, the con-
ditions of nutrition are aficcted : and, in a future lecture, I hope to
show how a change in any one of these conditions may appear as the
cause of inflammation, by being the first in the series of changes, in
which, in the complete morbid process, they are all involved.
The next subject may be the changes in the nutritive process itself ;
those which are commonly observed as the effects of inflammation,
when the process does not subside in the manner just described. They
are chiefly manifest (1) in a change of the material that is separated from
the blood into or upon the afi*ected tissue ; and (2) in changes of the
tissue itself. These changes usually coincide : and it may be generally
said, that in all inflammations, at least of vascular parts, there is at
once an increased exudation of fluid from the bloodvessels, and a dete-
rioration of the structures, of the afi*ected part. Either of these events
may, in certain cases, predominate over the other ; in some instances,
one alone of them may be observed ; but they so generally concur, that
a natural division of the inflammatory changes of the nutritive process
may be into those that are productive and those that are destructive.
Adopting, then, such a division, as of the effects of inflammation,
the description of the productive changes will include the histories of
the several efiiisions or exudations from the bloodvessels into the in-
flamed part, their developments, degenerations, and other changes.
In the account of the destructive efiects may be comprised that of the
various defects of nutrition, the degeneration, absorptioif, ulceration,
and death, to which the proper elements of the inflamed part, and, with
them, the. products of the inflammation, are liable.
I proceed, then, to these histories ; and first of the products of in-
fiammation or inflammatory exudations.
The materials that may be effused from the bloodvessels of inflamed
IMirts are chiefly these : serum ; blood ; lymph, or inflammatory exuda-
tion especially so called ; and mucus. The last two may be regarded
ui primary forms, from which, by development, or degent^ration, n»tii
others may be derived.
I. The effmion of »erum, except as the result of the loneetdegnetdf
inflamniittiou, or as a ililueiit of Other pruilucts, is probably ft rm
event. That which is usually, regarded as a serous efTusion in inlltm-
mation, is, in many cases, a fluid Ihat cnntalus fibritie or a Ghrof^enoiu
substance, which coagulates on exposure to the air and rci^cmlilt* tbr
Uquor xangtiini* rather than mere serum. It is this kind of efl'usioQ on
which Vogel* has fully written, under the designation of "Hjfiiwpi
fibrinosus." A good example of it may be seen in ihe fluid contained
in blisters, raised by the action of cantharidcs or heat applied to licaltlij
persons. And another form of li(]UJd effusion differs from serum, in
that, though it docs not coagulate, it contains a materinl capable of
organisstion into cells : such is the fluid that fillo the early
herpes, eczema, and some other cutaneous diseases.
The fluid that contains fibrine, and is most generally dneribodl
seroui effusion, may have the ordinary aspect of serum ; more
it is colorless or opalescent, like the liquid part of the blood which 004!
aces collecting for the formation of a buffy coat. The fibrine that '^
contains may remain in solution, or without coagidation, for an indeA"
nittj time within the body, but will coagulate readily when withdraw
For example, the so-called serous effusion which is ahundaot in the
teguments near the seat of an acute inflammation in deepiT parta, i
which flows out like a thin yellowish serum, after death, will sood fo
a auft, jelly-like clot, that is made succulent with the serum soaked
it. The fibrine appears tough, opaque-white, and stringy. wh«n tl
fluid is expressed from it, and shows all the recognized character* ^^s*
the fibrine of the blood. Thus, to mention but one case, which was n^^^
markable for the delay of the coagulation. A man received a coi^^"'
pound fracture of the leg, and it was followed liy phlegDionous JuBaii^^*"
mation and abscesses up the limb. As soon a£ the in^ammation h^^*^
subsided enough, the Umb was amputated ; and, three clays afterward. '^
in examining it, a quantity of serous-looking fluid ooted from thec^^^
through the integument. I collected some of this, and, after four hoor-^^
it formed ti perfect fibrinous clot; yet tho fibrine in this case had r^^*"
mained among the tissues without coagulating, for three days after tl^^^
death of the limb and for many more days during the life of the patien "•■
Such, too, are tho effusions like serum in blisters raised ou the »kiw- '
by heat or -cnntharides ; such the serous effusions of peritonitis, as ^ °
hernia, and of many cases of pleurisy and pericarditis. All these flui<L-^^
though they may retain their fluidity for weeks or months wiihin tl^^
body; during life, may yet coagulate when they are removed froai ll^^**
body. With these, too, may he reckoned, but as the most nearly
of the class, the fluid of common hydrocele; for I have seen ft
■ PathologiMhs Ana
i». p. 23.
8EKUM. 231
coagulnm form in such fluid spontaneously ; and the presence of fibrine
may always be proved by the formation of a clot when a small piece of
blood-clot, or of some organized tissue, is introduced into the fluid.
One can rarely tell why the coagulation of the fibrine in these cases
should be delayed ; there are, here, the same difficulties as are in all
the exceptions from the general rules of the coagulation of the blood.
But, it may be observed, the delay of the coagulation is a propitious
event in all these cases ; for, so long as the effusion is liquid, absorp-
tion may ensue on the subsidence of the inflammation ; but absorption
is more unlikely and tardy when the fibrine has coagulated. Thus,
large quantities of fluid, which, we may be sure, contained fibrine, may
disappear by absorption from the seats of acute rheumatism or gout,
or from the pleura or peritoneum, or from the subcutaneous tissues, and
leave only inconsiderable adhesion, or thickening of the affected part.
But, on the other hand, when, in the same class of cases, the fibrine
coagulates, it may be organized, and the usual consequent phenomena
of inflammation will ensue. Thus it is in the cases of what has been
called solid oedema, where, in the neighborhood of acute inflamma-
tion, an effusion long abides with all the characters of ordinary serous
oedema ; but, at length, the tissues are found indurated and adhering,
the oedema having consisted in the effusion of serum with fibrine, which
has coagulated and becomes organized in the seats of its effusion. Thus,
too, it is that the damage done by rheumatism in a part is, on the whole,
in direct proportion to the length of time it has subsisted there, and the
opportunity given by time for the coagulation of the fibrine.
From what I have said, it will appear that nearly all of what are
called serous effusions in inflammation are effusions of fluid containing
either fibrine, or a material that will organize itself into cells. But it
may be said that we often find, after death, effusions which contain
nothing but the constituents of serum, though produced in an inflamma-
tory process. If, however, we examine these cases more closely, they
will appear consistent with the others : some of the fluids will coagu-
late if kept for several hours, or if mixed with other serous fluids, or if
fragments of fibrine be placed in them ; in others we find flakes of
iHolecular matter, indicating that fibrine had been already coagulated.
Or that corpuscles had been formed, but that subsequently they were
disintegrated, or even partially dissolved ; and in some we may believe
that similar materials were decomposed in the last periods of life, or
^fter death.
On the whole, it seems sure that an effusion of serum alone is a rare
effect of inflammation, and that generally it is characteristic of only the
lowest degrees of the disease. Among the instances of it are, probably,
the cases of the chronic forms of hydrops articuli, some forms of hydro-
cephalus, and some cases of inflammatory oedema of the mucous mem-
brane, as in the oedema of the glottis, and chemosis of the conjunctiva.
In the nearly constant fact of the presence of organizable materials
282 PRODUCTS OP INFLAMMATION:
in the products of inflammation, we have one evidence of the likeness
between inflammation and the normal process of nutrition, and of its
difference from the merely mechanical obstructions or stagnations of the
blood. In these, the material efi'used from the blood is usually the
merely serous part : the fluids of anasarca and ascites will not coagu-
late ; they present neither fibrine nor corpuscles, except in the cases of
extremest obstruction, when, as in cases of ascites from advanced disease
of the heart, one may find flakes of fibrine floating in the abdomen, or
masses of it soaked and swollen up with serum.*
II. The second of the so-called inflammatory efl*usions is Blood.
Among the eff'usions of blood that occur in connection with the inflam-
matory process, many, as Rokitansky has explained, are examples of
hemorrhage from rupture of the vessels of lymph recently become vascu-
lar. The new vessels, or their rudiments, are peculiarly delicate ; and
being apt to rend, like the vessels of new granulations, with a very
slight force, especially when they are made turgid or dilated by an
attack of inflammation of the lymph, they will commonly be sources of
considerable bleeding. So, for example, it probably sometimes happens
when, as the expression is, a hydrocele is converted into a hsematocele ;
some lymph becoming vascular, and being submitted to even slight vio-
lence, its vessels break, and blood is poured into the sac. So, too, pro-
bably, it is with many or all the cases of what are called hemorrhagic
pericarditis. But of these, which may be called secondary hemorrhages^
I will speak hereafter.
Primary effusions of blood, i, e, efiiisions of blood poured from the
ruptured vessels of the inflamed part, and mingled with the lymph or
other inflammatory product, appear to be rare in some forms or locali-
ties of inflammation, but are almost constant in others. Thus, e.g. in
pneumonia, extravasatcd blood-corpuscles give the sputa their charac-
teristic rusty tinge. In the inflammatory red softening of the brain,
blood is also commonly efi'used ; and the condition of the vessels, which I
described in the last lecture (p. 212), may well account for their rupture.
There are also other cases of these eff'usions of blood in inflammation :
but I believe these imply no more than accidents of the disease.
We must not confound with hemorrhages the cases in which the in-
flammatory products are merely blood-stained, %, e., have acquired a
more or less deep tinge of blood through the oozing of some dissolved
* It has been supposed that, in mechanical dropsies, the etfusion of serum takes place
through the walls of the small veins, and that in iftflammations an equally mechanical effu-
sion of liquor sanguinis takes place through the walls of the capillaries and small arteries;
and this supposition is assumed fojr an explanation of the difference between a dropsical and
an inflammatory effusion. But I think that, in a merely mechanical obstruction of the blood,
as by disease of the heart, or compression of veins, the pressure of the blood cannot but be
increased alike in the veins, capillaries, and arteries, and that, in correspondence with this
uniformly diffused pressure, the increased effusion will take place at once through all these
vessels, in direct proportion to the permeability of their walls.
LYMPH. 233
coloring matter of the blood. The natural color of inflammatory exu-
dations is grayish or yellowish-white, and, even when they have become
vascular, their opacity in the recent state prevents their having any
uniform tint of redness visible to the naked eye. When inflammatory
products present the tinge of redness, it is either because of hemorrhage
into them, or because they have imbibed the dissolved coloring matter
of the blood ; and when this imbibition happens during life, or soon
after death, it is important, as implying a cachectic, ill-maintained con-
dition of the blood, in which condition the coloring matter of the cor-
puscles becomes unnaturally soluble. Thus, blood-stained efiusions are
among the evil signs of the products of inflammation during typhus and
other low eruptive fevers, in syphilis, and in scurvy.
III. Serous efi'usions, then, appear to be rare as the results of in-
flammation, and efi'usions of blood are but accidents in its course. The
chara<;teristic primary product of the inflammatory process is the liquid
which the elder writers named "lymph,'* "coagulating or coagulable
lymph," and which more lately has been called "exudation,'' or " in-
flammatory exudation."* It is, probably always, at its first exudation
a pellucid liquid, which passes through the bloodvessels, especially the
capillaries of the inflamed part, or, perhaps, only from them ;t and its
most characteristic general properties are, that it is capable of organiza-
tion even while its external circumstances remain apparently the same,
and that, thus organized, it may proceed by development to the con-
struction of tissues like the natural structures of the body.
The form assumed by inflammatory lymph in its primary organiza-
tion is not always the same. There are, rather, two chief forms of or-
ganization, which, though they are often seen mixed in the same mate-
rial, are yet so distinct as to warrant the speaking of two varieties of
inflammatory lymph by the names of fibrinous and corpuacular.X
To the fibrinous variety belong, as typical examples, all the instances
in which inflammatory lymph, eff'used as a liquid, coagulates into the
solid form and yields, when the fluid is pressed from the solid part,
either an opaque whitish, elastic substance, having the general pro-
* It is to be regretted that we have no distinct appellation for this substance. To call it
** lymph" is objectionable, while, already, the same word is employed for the fluid in the
lymphatic vessels, with which it is probably not identical, though they are in many respects
similar. And the term ^* exudation*' is yet more objectionable, since it has to be employed
as well for the act of separation from the blood as for the material separated ; or, even if
it be limited, as the Germanized " Exsudat" is, to what has oozed from the blood, still, it is
equally applicable to all the liquid products of inflammation, and not more to any one of
them than to the serum of a dropsy, or the material separated for normal nutrition. On the
whole, in accordance with the generally good rule or retaining an old term' till a better new
one is proposed,. the words 'inflammatory lymph'* appear least improper.
t See a remarkable case by Mr. Bowman ; Lectures on the Eye, p. 44.
X Corresponding varieties are distinguished or implied by Vogel,p. 30, Dr. Andrew Clark
(Medical Gazette, vol. xliii, p. 286), and others.
16
284 PRO.DUCTS OF INFLAMMATION:
perties of the fibrine of the clot of blood, or the softer, and, as it is
supposed, the less perfect or less developed fibrine of the chyle or the
absorbed lymph.
Such examples of nearly pure fibrinous inflammatory lymph are
found, in the cases already referred to, among what have been supposed
to be eflTusions of mere serum. Such are many instances of effusions
produced by blisters and other local irritations of the skin in healthy
men: such, too, are most of the effusions in acute inflammations of
serous membranes, especially in those of traumatic origin, and in those
that occur in vigorous men. If in any of these cases the lymph be
examined after coagulation, it may be hard to distinguish it from the
fibrine of the clot of blood. The layers of fibrinous lymph thus formed
may be known to the naked eye, when on serous membranes, by their
peculiar elasticity and toughness, their compact and often laminated
structure, their grayish or yellowish-white and semi-transparent aspect,
and their close adhesion to the membrane even before they have become
vascular.
In the corpuscular variety of inflammatory lymph no coagulation, in
the ordinary sense of the word, takes place ; but corpuscles form and
float free in the liquid part. Typical examples of this variety are found
in the early-formed contents of the vesicles of herpes, eczema, pemphi-
gus, and vaccinia ; in the fluid of blisters raised in cachectic patients ;
in some instances of pneumonia ; and in some forms of inflammation of
serous membrane.
The lymph, or exudation-corpuscles or cells, found in such lymph as
this, present numerous varieties in their several developments and de-
generations ; but in their first appearance resemble very nearly the
primordial condition of the corpuscles of chyle and absorbed lymph,
the white corpuscles of the blood, and those of granulations.*
The first discernible organic form in the lymph of herpes, for example,
is that of a mass of soft, colorless, or grayish-white substance, about
35^^th of an inch in diameter, round or oval, pellucid, but appearing,
as if through irregularities of its surface, dimly nebulous or wrinkled.
It does not look granular, nor is it formed by an aggregation of gra-
nules ; nor, in its earliest state, can any cell-wall be clearly demon-
strated, or any nucleus, on adding water. But, in a few hours, as the
development of this cell-germ proceeds, a pellucid membrane appears to
form ad a cell-wall over its whole surface ; and now, when water is added,
it penetrates this membrane, raising up part of it like a clear vesicle^
* I have already (p. 141) referred to this fact of a single primordial form existiag in tha^
rudiments of many structures, which in later periods of their existence are widely different-
It is a repetition of a fact in the first development of beings. In the early embryo, it^^f
most ultimate forms are developed from a nearly uniform mass of primordial embryo o*"
germ-cells. And so it is in later life ; many of both the normal and the morbid structured
start from one primordial form, and, thence proceeding, diverge more and more widely i^
attaining their several perfect shapes.
LYMPH.
4
r -
l^-
-ml
1^ »
, *" -
.f J^
c^i
while upon the other part the mass retreats, or subsides, and appc£
more nebulous or grumous than before. In yet another state, whit
appears to be a later stage of development, the action of water not onl
raises up a cell-wall, but breaks up and disperses the outer part of th
contents of the cell, and exposes in the interior a nucleus w hich is com
monlj round, clearly defined, pellucid, and attached to the cell-wall.'*'
From the various developments of these cells are derived, in the pro-
ducts of inflammation, all the several forms of corpuscles that are de-
scribed as plastic cells, fibro-cells, caudate or fibro-plastic cells, and some
forms of filaments. These correspond with the development of granula-
tion-cells, already described (p. 140). On the other hand, from their
various degenerations, descend those known as pus-corpuscles, granule-
cells, granule-masses, inflammatory globules, and much of the molecular
and debris-like matter that makes inflammatory efi'usions turbid.
The examples of inflammatory lymph which I have quoted are such
as may be considered typical of the two varieties : the first, in which,
spontaneously coagulating, it presents fibrine, either alone or mingled
with very few corpuscles ; and the second, in which corpuscles are found
alone, or with only a few flakes of fibrine. But, in a large number of
examples of inflammatory lymph, the fibrine and the corpuscles occur
together, mixed in various proportions, the one or the other preponde-
rating. Such instances of mixed lymph are found in the fluid of blisters
in all persona not in full health ; in all but the freshest inflammations of
serous membranes; in most of the inflammatory deposits in cellular
tissue, and in most of the viscera ; and in the false membranes of croup
and other similar inflammations of mucous membranes.
Now, in general, and in the first instance, the proportions of fibrine
and of corpuscles that are present in the lymph of an inflammation, will
determine the probability of its being organized, or of its degenerating.
The larger the proportion of fibrine in any specimen of inflammatory
Ijmph (provided it be healthy fibrine), the greater is the probability of
its being organized into tissue ; such as that of adhesions, indurations,
and the like. On the other hand, supposing the other conditions for
development or degeneration to be the same, the larger the proportion
of corpuscles in lymph, the greater is the probability of suppuration or
Borne other degenerative process, and the more tardy is any process of
development into tissue. In other words, the preponderance of fibrine
iXi the lymph is generally characteristic of the " adhesive inflamma-
tion ;" the preponderance of corpuscles, or their sole existence, in the
liquid, is a general feature of the " suppurative inflammation/*!
It may be that the cell-fbrms met with in the fluid of herpes, and other vesicular ernp-
are dereloped fVom the nuclei, or immature cells of the deeper layers of the epidermis,
lucfa, owing to the separation and elevation of the superficial cuticular layers during the
^Miliar fbrroafion, became detached, and float freely in the fluid,
t In this Tiew, the fibrinous and the corpuscular varieties of lymph nearly corresr*
ith tboM which Dr. Williams, in his Principles of Medicine, and others, have namf
and aplastic; but they do not completely do so. In different instances of both
286 PRODUCTS OP INFLAMMATION:
The knowledge of this fact may help us to learn the several condi-
tions on which, in the first instance, depend these two forms of inflam-
mation, the contrast between which has lost none of its importance
since the time of Hunter. I will therefore at once enter on this ques-
tion,— what are the conditions that determine the production of one
or the other variety of lymph ; the fibrinous, which, apt for development,
is as the symbol of the adhesive inflammation, or the corpuscular,
which, prone to degenerate, may be that of the suppurative inflam-
mation ?
The conditions which are chiefly powerful in determining the character
and tendency of inflammatory lymph are three ; namely, —
1. The state of the blood ;
2. The seat of the inflammation ;
8. The degree of the inflammation.
First, in regard to the influence of the state of the blood in deter-
mining the characters of an inflammatory product, Rokitansky has
happily expressed it by saying that " the product of the inflammation
exists, at least in part, in its germ preformed in the whole blood."
Some, indeed, have supposed that lymph is only the liquor sanguinis
exuded in excess through the walls of the bloodvessels ; but of this
opinion we cannot be sure, and many facts, such as the occurrence of
inflammatory lymph which does not spontaneously coagulate, e. g. in
herpes, will not agree with it. Still, it is not difficult to show that a
certain character is commonly impressed by the state of the blood on
the inflammatory product from it.*
I will not refer here to the cases of inoculable diseases, in which some
of the morbid material that was in the blood may be incorporated with
the product of a local inflammation, though in these the correspondence
of the blood and the inflammatory product is manifest enough ; but L
will refer to cases that may show a more general correspondence be —
tween the two, a correspondence such that, according to the state c^"^
very diverse degrees of plastic property may be found ; and the occurrence of developm&. ~'^
or degeneration depends on many things besides the primary characters of lymph. Th- -^«
more nearly correspond with what Rokitansky (Pathologische Anatomie, i, 96) has (^^hi
tinguished as fibrinous and croupous; the varieties which he names croupous «, /d,and y, i
presenting the several grades of lymph in which the corpuscles gradually predominate m^ -^)i
and more over the fibrine, and assume more of the characters of the pus-cell. I would b^^^v
used his terms, but that, in this country, we have been in the habit of considering crouf^^m^ou
exudations to be peculiarly fibrinous.
I described the healing of subcutaneous wounds as usually accomplished by a fibriirrmOB^
material, and that of open wounds by cells which, with their intercellular substance -, de-
veloped into fibres. These materials exactly correspond in appearance and modes oC de-
velopment with the fibrinous and corpuscular varieties of inflammatory lymph. And ^^rbat
was then said of the liability of the cells formed in the repair of open woundsto be arr«5/ed
in their development or to degenerate into pus-cells and lower forms, and of the consequent
insecurity of this mode of repair as compared with the subcutaneous, is confirmed by t^^^
corresponding history of the two varieties of lymph.
* See Ormero^l: Lectures on Valvular Disease of the Heart. — Medical OoMette^ 1851.
LYMPH. 237
the blood, so is the lymph more fibrinous or corpuscular ; more charac-
teristic of the adhesive or of the suppurative inflammation.
Some of the best evidence for this is supplied by Rokitansky, in the
first volume of his "Pathological Anatomy;'* a work that I cannot
again mention without a tribute of respect and admiration for its au-
thor, since in it, more than in any other of his writings, he has proved
himself the first among all pathologists, in knowledge at once profound,
minute, and accurate, in power of comprehending the vastest catalogue
of single facts, and in clear discernment of their relations to one an-
other, and to the great principles on which he founds his systems. In
this work, he has shown clearly, that the characters of inflammatory
deposits, in difierent diatheses, correspond very generally and closely
with those of the coagula found in the heart and pulmonary vessels ;
and that, in general, the characters of inflammatory lymph, formed
daring life, are imitated by those of clots found in the body after death,
when the fibrine of the blood may coagulate very slowly, and in contact
with organic substances.
Other evidence may be obtained by examining the products of simi-
lar inflammations excited in several persons, in whom the state of the
blood may be considered dissimilar. And here, the evidence may be
more pointed than in the former case ; for, if it should appear that the
same tissue, inflamed by the same stimulus, will, in different persons,
yield different forms of lymph, we shall have come near to certainty that
the character of the blood is that which chiefly determines the character
of an inflammation.
To test this matter, I examined carefully the materials exuded in
blisters, raised by cantharides plasters, applied to the skin in thirty
patients in St. Bartholomew's Hospital. Doubtless, among the results
thus obtained, there might be some diversities depending on the time
and severity of the stimulus applied ; still, it seemed a fair test of the
question in view, and the general result proved it to be so. For, although
the differences in the general aspects of these materials were slight, yet
there were great differences in the microscopic characters ; and these
differences so far corresponded with the nature of the disease, or of the
patient's general health, that, at last, I could generally guess accu-
rately, from an examination of the fluid in the blister, what was the
^neral character of the disease with which the patient suffered. Thus,
in cases of purely local disease, in patients otherwise sound, the lymph
tiius obtained formed an almost unmixed coagulum, in which, when the
fluid was pressed out, the fibrine was firm, elastic, and apparently fila-
mentous. In cases at the opposite end of the scale, such as those of
^vanced phthisis, a minimum of fibrine was concealed by the crowds of
corpuscles imbedded in it. Between these -^were numerous intermediate
conditions which it is not necessary now to particularize. It may suf-
fice to say that, after some practice, one might form a fair opinion of
^he degree in which a patient was cachectic, and of the degree in which
238 PRODUCTS OF INFLAMMATION:
an inflammation in him would tend to the adhesive or the suppuratiye
character, by these exudations. The highest health is marked by an
exudation containing the most perfect and unmixed fibrine ; the lowest^
by the formation of the most abundant corpuscles, and their nearest
approach, even in their early state, to the characters of pus-cells. The
degrees of deviation from general health are marked, either by in-
creasing abundance of the corpuscles, their gradual predominance over
the fibrine, and their gradual approach to the characters of pus-cells ;
or, else, by the gradual deterioration of fibrine, in which, from being
tough, elastic, clear, uniform, and of filamentous appearance or filamen-
tous structure, it becomes less and less filamentous, softer, more paste-
like, turbid, nebulous, dotted, and mingled with minute oil-molecules.
I would not make too much of these observations. They are not
enough to prove more than the rough truth, that the products of similar
inflammations, excited in the same tissue, and by the same stimulos,
may be in diflFerent persons very diflFerent, varying especially in accord-
ance with the several conditions of the blood. Yet, simple as the ob-
servations are, they may illustrate what often seems so mysterious ;
namely, the different issues of severe injuries inflicted on difierent per-
sons. To what, more than to the previous or some acquired condition
of the blood, can we ascribe, in general, the various consequences that
follow the same operations on difi*erent patients ? The local stimulus^
and the conditions by which the inflammatory product finds itself sur-
rounded, may be in all alike : but, as in the simpler case of the blister,
the final events of the inflammation are in accordance with the state of
the blood.
I cannot doubt that a yet closer correspondence between the blood,
and the products of inflammation derived from it, would be found in a
series of more complete observations ; in such, for instance, that the
characters of the blood drawn during life, or, much better, of the clots
taken from the heart after death, might, in a large number of patients,
be compared with thdse of inflammatory exudations produced, as in the
cases I have referred to, by the same stimulus applied to the same
tissues. In the few cases in which I have been able to make sucbi.
examinations, this view has been established ; and it is confirmed b
the parallelism between the varieties of lymph that may be found i
blisters, and the varieties of the fibrinous coagulain the heart describe «
by Rokitansky.* The varieties of solidified fibrine which he classes ^m^'
fibrines 1, 2, 3, 4, are very nearly parallel with what I have enumerat^s^^
as the stages from the best fibrinous to the corpuscular lymph ; aik.
as I have already implied, he regards these clots found in the heart a
vessels as representing the different " fibrinous erases** or diatheses
the blood.
* Pathologische Anatomie, B. i, p. 142.
LYMPH. 239
I mentioned^ as the second condition determining the character of
inflammatory lymph, the seat or tissue which the inflammation occupies.
I need hardly remind you that, since the time of Bichat, there has
been a general impression that each tissue has its proper mode and
product of inflammation. The doctrines of Bichat on this point were,
indeed, only the same as Mr. Hunter held more conditionally, and,
therefore, more truly ; but they gained undisputed sway among the
principles of that pathology which rested on general anatomy as its
foundation.
The facts on which it is held that, in general, each part or tissue is
prone to the production of one certain form of inflammatory exudation,
are such as these : that, e, g, in the apparently spontaneous inflamma-
tions of the skin, lymph with corpuscles alone is produced, as in herpes,
eczema, erysipelas ; that in serous membranes, the lymph is commonly
fibrinous, and has a great tendency to be organized, and form adhe-
sions ; that in mucous membranes there is as great a tendency to sup-
puration ; that in the lungs, both fibrine and corpuscles are abundant
in the lymph, and the corpuscles have a remarkable tendency to degene-
rate into either pus-cells or granule-cells ; that in the brain and spinal
cord the tendency is to the production of a preponderance of corpuscles,
that quickly degenerate into granule-cells, while in the areolar tissue,
both fibrine and corpuscles appear, on the whole, equally apt to degene-
rate into pus, or to be developed into filamentous tissue.
Now these are, doubtless, facts ; but the rules that it is sought to
establish from them are not without numerous exceptions. The in-
stances I have lately quoted show that, in one tissue at least, the skin,
the product of inflammation will vary according to the condition of the
blood, although the inflammation be always similarly excited by the
same stimulus. So, too (as Mr. Hunter remarks*), if it were the tissue
alone that determines the character of an inflammation, we ought to
Iiave many forms of inflammation in the same stump after amputation ;
nrhereas, all is consistent, or the difi'erences among the tissues are only
differences of degree ; they all adhere, or all granulate and suppurate,
or all alike inflame and slough.
It is therefore not unconditionally true that each tissue has its proper
xnode and product of inflammation. It has been too much overlooked
^hat a morbid condition of the blood, or perhaps even of the nervous
"Sbrce, may determine, at once, the seat of a local inflammation, and
^he form or kind of inflammatory product. Thus, e. g, the variolous
^^ndition of the blood may be said to determine, at once, an inflamma-
^on of the skin, and the suppurative form of inflammation ; for, in
variola, whatever and wherever inflammations arise, they have a suppu-
rative tendency. So, in rheumatism, whether it be seated in muscles,
ligaments, or synovial membranes, in serous membranes, or in fibrous
* Works, vol. iii, p. 313.
240 PRODUCTS OF INFLAMMATION:
tissues, there appears the same tendency to serous and fibrinous effu-
sions, which are slow to coagulate or organize, and even less prone to
suppuration. The same might be said of the local inflammations that
are characteristic of typhus and of gout, and, I believe, of all those dis-
eases in which a morbid condition of the blood manifests itself in some
special local error of nutrition. And all these cases are illustrative of
the general truth, that each morbid condition of the blood is prone both
to produce an inflammation in a certain part, and to give to that inflam-
mation a certain form or character.
Cases, however, remain, that prove some influence of the tissue in de-
termining the product of its inflammation ; in determining, I mean, the
primary form, as well as the later development, of the product : and
the true influence of the tissue in this respect is best shown in some of
the cases in which the inflammation, excited, apparently, by the same
means, has happened coincidently in two or more very different parts
in the same person. Thus we may find, e, g, that, in pleuro-pneumonia,
the lymph on the pleura is commonly more fibrinous than that within
the substance of the lung ; and adhesions may be forming in the one,
while the other is suppurating. In cases of coincident pneumonia and
pericarditis, the lymph in the lung may appear nearly all corpuscular,
and all the corpuscles may show a tendency to degenerate into granule-
cells while the lymph on the pericardium may have a preponderance of
fibrine, and what corpuscles it has may tend to degenerate into pus-cells.
So, too, one may find, in the substance of an inflamed synovial mem-
brane, abundant lymph-cells, while the exudation on its surface may
appear purulent.
I have said that the fluid of the sac in cases of strangulated hernia
coagulates on withdrawal from the body : it may be regarded as a mix-
ture of serum and fibrinous lymph from the inflamed serous membrane.
But, in a case in which I was able to exaniine a pellucid fluid contained
in large quantity in the cavity of the strangulated intestine, and which
appeared to be the nearly pure product of inflammation of the mucous
membrane, there was no fibrine ; the fluid was albuminous, and contained
abundant lymph-cells.
Other instances of this might be mentioned. These, however, may
seem enough to establish the influence of the second condition that I
mentioned ; namely, the seat of an inflammation, as determining the
character of its products.
The third condition on which the character of the lymph chiefly de-
pends is, the degree of the inflammation producing it.
The influence of a tissue, in determining the character of the lymph
formed in its inflammations, may be in some measure explained, by be-
lieving that the primary product of inflammation is, often, a mixture of
lymph, and of the secretion, or other product, of the inflamed part,
more or less altered by the circumstances of the inflammation.
LYMPH. 241
When it is seen that in inflammations of bone the lymph usually ossi-
fies ; in those of ligament, is converted into a tough ligamentous tissue ;
and that, in general, lymph is organized into a tissue more or less cor-
responding with that from whose vessels it was derived : it is usually
concluded that this happens under what is called the assimilative influ-
ence of the tissues adjacent to the organized lymph. But we may
better explain the facts, by believing that the material formed in the
inflammation of each part partakes, from the first, in the properties
of the natural products of that part ; in properties which, we know,
often determine the mode of formation independently of any assimila- .
tive force (p. 61).
We have some evidence of this in the products of inflammation of
secreting organs, the only structures the natural products of which we
can well examine in their primary condition. In a moderate amount of
inflammation of a secreting gland, the discharge is usually a mixture
of the proper secretion in a more or less morbid state, and of the in-
flammatory product. Thus we find morbid urine mixed with fibrine, or
albumen, or pus. In cases of inflamed mucous membranes, the pro-
duct is often a substance with characters intermediate between those of
the proper mucous secretion and those of lymph. Or, again, in serous
membranes, we may perceive a relation between their natural secretion
and the usual products of their inflammation.
Now, these considerations are equally illustrative of the influence of
the third among the conditions enumerated as determining the charac-
ter and tendency of inflammatory products; namely, the degree or
severity of the disease. For, as a general rule, the less the degree of
inflammation is, the more is the product like that naturally formed in
or by the part, till we descend to the border at which inflammation
merges into an exaggerated normal process of secretion : as in hydrops
articuli, hydrocele, coryza, &c.
These, it may be said, are only instances of secretions. But the
instances of the so-called inflammatory hypertrophies may be regarded
as parallel with those just referred to ; for the analogies between secre-
tion and nutrition are so numerous, the parallel between them is so
close, that what can be shown of one may be very confidently assumed
of the other. We may therefore believe, that, in the inflammation of
any part, the product will, from the first, have a measure of the par-
ticular properties of the material employed in the normal nutrition of
the part : that, as in the inflammation of a secreting organ, some of the
secretion may be mingled with the product of the inflammation, so in
that of any other part, some of the natural plasma, i. e., some of the
natural material that would be effused for the healthy nutrition of the
part may be mingled with the lymph. The measure of likeness to the
natural structure acquired by the inflammatory product in its develops
ment, will thus bear an inverse proportion to the severity of the in-
242 PRODUCTS OP INFLAMMATION:
flammation ; because, the more the conditions of nutrition deviate from
what is normal the more will the material effused from the vessels
deviate from the normal type. In severest cases of inflammation we
may believe that unmixed lymph is produced, the conditions of the due
nutrition of the part being wholly changed ; but when the inflammation
is not altogether dominant, its product will be not wholly contrary to
the natural one, and will, from the first, tend to manifest in its. develop-
ment some characters correspondent with those of the natural forma-
tions in the part. Thence, onwards, this correspondence will increase as
the new tissue is itself nourished ; as scars improve, so do false mem-
branes and the like become more and more similar to natural tissues.
To sum up, then, what may be concluded respecting the conditions
that, in the first instance, may determine the adhesive or suppurative
characters of an inflammatory exudation : they are, 1st. The state of
the blood — its diathesis or crasis — the power of which is evident in that
the same material may be exuded in many inflamed parts in the same
person ; in that this material may exhibit peculiar characters corre-
spondent with those of the blood itself; and in that, in difiiBrent personSi
an inflammation excited in the same tissue, and by the same stimulus,
will produce different forms of lymph, corresponding with differences of
the blood. 2d. The seat of the inflammation, and the tissue or organ
affected ; of which the influence is shown by cases in which, with the
same condition of blood, different forms of lymph are produced in
different parts or organs. 3d. The severity, and acute or chronic
character, of the inflammatory process, according to which the product
deviates more or less from the character of the natural secretion or
blastematous effusion in the part.
The primitive character or tendency of any case of inflammation
might be represented as the resultant of three forces issuing from these
conditions.
The last product of inflammation of which I have to speak is Muciu.
Peculiar diflficulties, owing to imperfect investigations of what normal
mucus really is, beset this portion of our subject.
Normal mucus, so far as it has been examined, is a peculiar viscid,
ropy, pellucid substance, which, of its own composition, has no corpus-
cles or organized particles. Such mucus is to be found in the nasal
cavities of sheep and most large mammalia, and in the gall-bladder
when its duct has been totally obstructed. In these parts, mucus may
be found without corpuscles ; and probably there are other examples
of such pure and unmixed mucus.
With all these, however, accidental mixtures commonly occur of
epithelial particles from the mucous membrane, and of corpuscles from
the imbedded mucous follicles. And these particles vary according to
the seat of the membrane, the fluid with which the mucus may be mixed,
MUCUS. 243
as gastric acid, intestinal alkali, &c,, the time the mucus may lie before
discharge, and other such conditions. "*"
The first effect of a stimulation within the normal limits is to increase
the secretion of the proper mucus, making it also more liquid ; to in-
crease the quantity of the epithelium cast off with the liquid ; and,
often, to induce the premature desquamation of the epithelium, so that
particles of it imperfectly formed may be found in the mucus. Many
of these immature epithelial particles have been named mucus-corpuscles
or mucus-cells.
In an established inflammation of a mucous membrane, there appear,
mixed with mucus, and with imperfect or degenerate epithelium, ma-
terials which closely resemble, if they are not identical with, the lymph-
products of inflammation in other parts. I am, indeed, disposed to
think that we should not draw a strong contrast between the inflamma-
tory products of mucous membranes and those of serous membranes, and
other parts, except in relation to the material with which, in the several
cases, they are mixed. For, in certain inflammations of mucous mem-
branes, we find fibrinous exudations, as in Hunter's experiment of
injecting strong irritants into the vaginae of asses ;t they are found,
also, but less pure, in croup and bronchial polypus ; J and I have seen
them in the renal pelvis, ureters, and bladder, in a case of calculus. In
other cases, we find, either without fibrine, or mixed with minute soft
flakes of it, corpuscles which are, also, commonly called mucus-cor-
puscles, but which appear to differ from those in the lymph already
described, only because of the peculiarly viscid fluid in which they lie.
All appear to be, alike, lymph-corpuscles ; but in the one case they lie
in a serous, in the other in a mucous fluid, in which they appear clearer,
more glistening, more perfectly pellucid, less plump, and are less acted
on by water.
From these inflammatory products in mucus may be derived, by
Tarions degenerations of the fibrine, the flaky and molecular materials
which commonly make morbid mucus look turbid and opaque ; and by
corresponding degenerations of the corpuscles the more frequent pus-
cells, which make the transition to the complete pus formed on mucous
membranes in active inflammation.
•Such degenerations are more frequent in the products of inflamed
mucous surfaces than are any forms of development. Development of
fibrine, I suppose, never happens here ; but in the corpuscles some indica-
* Some obflervations have recently been recorded by Remak and Ebertb (Virchow^s
Archiy, yol. zx, p. 198, vol. xzi, p. 106), which appear to show that the mucu»<;orpu8cles
may form in the interior of the epithelium cells covering the surface of the mucous mem-
Inane. Eberth considers that the nucleus of the epithelium cell divides, and that each of
die divisiooB become invested with a finely granular mass derived from the cell-contents, so
dwt several mucus-corpuscles may arise in a single epithelium cell. The rupture of the
wall of the latter sets the corpuscles free.
f Worka, voL iii, p. 341. Museum of the College, Nos. 83, 84.
X See Henlo, in his ZeitschriA, t. ii, p. 178.
244 PRODUCTS OP INPLAMMATION:
tions of it may be found, especially when the inflammation is very slight,
as in the end of a bronchitis.
In this case, among the corpuscles, many may be found enlarged,
having distinct cell-walls, and clear, well-defined nuclei with nucleoli.
But among these there are usually many that present a peculiar
pigmental degeneration. In the gray, smoke-colored mucus, commonly
expectorated at the close of bronchitis, the peculiar color, though com-
monly ascribed to the mixture of inhaled carbon, is due to the abun-
dance of cells containing more or less numerous black pigment-granules.
Particles of carbon or soot may by chance be present, but they only
Fig. 83.
trivially contribute to the color ; it depends on the number of these
pigment-cells, to which it is easy to trace the transitions from the
lymph or mucus-corpuscles. The chief stages of transition are seen in
that the cells enlarge to a diameter of about jBo^jth of an inch, become
clearer, and acquire one or two clear oval nuclei ; but, at the same time,
minute black granules, almost like those of melanotic cells, accumulate
in them ; and these, increasing in number and clustering, may at length
fill the whole cell, while the nucleus disappears. Subsequently, the cell-
wall may burst or dissolve, and the black granules be set free.
It can hardly be supposed that the black granules are in any way
derived from inhaled carbon, although it seems that this kind of mucus
is most abundant in those who are exposed to atmospheres laden with
coal-smoke; for the color is completely destroyed by immersing the
mucus in nitric acid or solution of chlorine. The occurrence of such
pigment-cells, being, I believe, peculiar to the mucus of the air-passages,
may be connected with the general tendency of inflammatory products
to imitate the properties of the natural products of the inflamed part ;
for they closely resemble the black pigment-cells from which the lungs
and bronchial glands derive their black spots and streaks and other
marks. And it may be added, that their peculiar abundance in the
slightest forms of bronchitis, compared with their absence in acute
cases, aflfords another example, that the likeness of the morbid to the
natural product is inversely proportionate to the severity of the inflam-
mation.
LYMPH. 245
LECTURE XV.
DEVELOPMENTS OP LYMPH.
In the last lecture I considered part of the contrast between the pro-
cesses of nutrition in the normal and in the inflammatory state, endea-
voring to illustrate the nature of the materials exuded from the blood-
vessels of inflamed parts. The contract in this particular cannot, indeed,
be accurately drawn : for we have, as yet, no certain knowledge of either
the properties or the quantity of the material separated from the blood,
for the ordinary nutrition of each part ; we have no normal standard
wherewith to compare, in this respect, the processes of disease. It is
evident that the exudation in an inflamed part is superabundant ; but
its error in quality can be proved only by its diversity in various cases,
and by the differences which it commonly presents in the rate and
method of its development or degeneration. It is of these processes in
the exuded lymph, and of the contrast between them and the normal
maintenance of a part, that I propose next to speak.
The biography of the lymph-product comprises much of the most
important part of the pathology of inflammation : and if it were required
to point out what, since Hunter's time, has contributed most to the pro-
gress of general pathology, one could scarcely hesitate to name the full
appreciation of the fact, that inflammatory lymph, and other primary
products of disease, have an independent life, and are of their own
nature, capable of appropriate development, degeneration, and disease.
We may regard this as one of the best achievements of the observations
which Schleiden and Schwann began to generalize; for, till it was
clearly apprehended, the idea of a part being organizable meant scarcely
more than that it admitted of being organized by the forces of the parts
around it ; that it could be built up by the arteries, and modelled by
the absorbents, as a material plastic, yet passive, in the hands of work-
men. Hence was derived the erroneous direction of inquiries, which
sought for bloodvessels as the essential characters of organic life in a
part ; and for their varieties of size, and number, and arrangement, as
the measures of the ability and method of development.
Now, more truly, we may study the lymph, as having a life only so
dependent on the blood and vessels as are all the tissues of the body —
dependent on them as conditions of life, but not as sole arbiters of the
method or direction of the vital transformations. And I venture to
think, that the chief aim of our observations, in this part of the patho-
logy of inflammation, should be to learn, now, the exact relation in
which the several products of inflammation stand to certain primary
forms, as developments or degenerations from them. The catalogue of
various corpuscles is already swollen to an extent that is confusing to
those who are familiar with them, and repulsive to those who would
246 DEVELOPMENT OF LYMPH:
begin to study them. It would be an easy task to increase it, and it
might have a seeming of accuracy to do so ; but what we want, is such
a history of the inflammatory lymph, that we may arrange the compo-
nents of this catalogue as indicating so many progressive stages of
development, degeneration, or disease, in the primary products of in-
flammation. An attempt to construct such a history is the more ad-
visable, for the sake of the illustration which it may afford to the history
of normal structures. There are, as I have already said, no normal
instances in which we can see the materials that are effused for the
nutrition of parts ; but we may assume something concerning them and
their progressive changes from the analogy of the materials that are
more abundantly produced in inflammations.
I propose, then, to devote the present lecture to some general, and
only a very general account of the developments of lymph. But let
me first state the sense in which the term development is here to be
employed.
I have said (pp. 27 and 86), that in the generally accepted meaning
of development, we have adopted an arbitrary standard of comparison,
in the assumption that the nearest approach to organic perfection is in
the human body at the age of manhood. The assumption may be right
on the whole ; and a less arbitrary definition of development would,
probably, be less useful ; yet it may be observed, that in what we take
for the period and standard of perfection, many parts that were once
highly organized and active have passed away, as the thymus gland;
and some are, in certain respects, rather degenerated than developed,
as the renal capsules and the bones. Development, in its highest sense,
should imply not merely that a part becomes more fit for membership
under the most perfect economy, but also that such fitness is acquired
with greater complexity of chemical composition, or with greater evi-
dence of formative or other organic power, or with greater difference
from the structure or composition of lower beings. With none of these
characters of development does such a process as that of ossification
agree ; and, therefore, as I have said before, when we call it the de-
velopment of bone from cartilage, it should be with the understanding
that the term is applicable only because bone is the proper material of
the skeleton of the adult human body.
This distinction is important in the pathology of inflammation. In
all true or complete development, we may believe there is a larger ex-
penditure of vital force than in any other organic act ; for all such de-
velopment, too, the external conditions need to be the most complete,
and the least interfered with ; such development is the highest achieve-
ment of the formative force, the highest instance of what might be
understood as "increased action" in a part.
To speak, therefore, of the development of inflammatory products,
when already the normal development of the body is completed, may
NBCESSARY CONDITIONS. 247
seem to imply the exercise of nnusnal vital force ; the renewal, as it
• were, of the pristine embryonic vigor ; and the existence of conditions
more favorable for nutrition than even those of health are. But we
may be led to judge differently, if it should appear that most or all of
the so-called developments of inflammatory products are instances in
which the tissues, though they are formed into the likeness of such as
exist in the perfect human frame, yet acquire characters of lower or-
ganization than those they had in their earliest state. It will appear
that they are such ; and that however much the inflammatory products
may become, by their changes, better suited for the general purposes
of the economy, they are, in relation to their own condition, rather
degenerated than developed. The changes that they undergo are,
therefore, not always declaratory of a large expenditure of vital force ;
they are not such as the term "sthenic,'* or "increased action," ap-
plied to the inflammatory process, would suggest ; not such as to imply
that it is an exaggeration of any normal method of nutrition.
With this understanding, however, the changes I shall presently de-
scribe may be called developments of inflammatory lymph or exudation ;
they are developments in the sense of being approximations to the like-
ness of the natural tissues of the adult human body.
In the last lecture I spoke, generally, of the conditions upon which
depends the production of such inflammatory lymph as may be most
apt for development. They are all such as favor the production of a
Ijmph rich in fibrine, and that fibrine clear, homogeneous, elastic, tough,
and filamentous. But even such lymph as this may altogether fail to
be developed, or may be arrested in any stage of its development, and
turned into the downward course of degeneration, unless favorable ex-
ternal conditions are present with it. For the development of lymph,
of whatever form, nearly all those conditions are requisite which are
necessary for the normal development of the proper constituents of the
body. It needs, in general, the due supply of healthy and appropriate
blood, the normal influence of the nervous force, and, for the highest
and latest forms of development, the normal conditions of the proper
elements of the affected part.
Now, the existence of these conditions for the development of lymph
implies a ce&sation of the inflammatory process, and a recovery from
whatever originated or maintained the inflammation. So long as in-
flammation lasts, no high development of the exudation already formed
will take place ; rather, fresh lymph will be continually exuded, hinder-
ing the due process of development, and hindering it the more, because,
as the general health suffers through the continuance of the disease, so
the lymph freshly formed will be less and less prone to organization.
We may see this illustrated in bad cases of pleurisy. The layers of
lymph next to the pleura are always more prone to organization than
the later-formed layers that lie next the cavity ; while within the
cavity all the lymph may retain its fluid form, or may have degenerated
248 DBVBLOPMENT OP LYMPH:
into pus. So, more openly, we may see an illustration of the ill effects
of abiding inflammation, in the healing of wounds by granulation. An'
inflammation, ensuing or continuing in the wound, hinders all develop-
ment of granulation-cells, even though it may be too slight to hinder
their formation, and may be favorable to the production of the ichor-
and pus-cells. We may truly say, that the conditions most favorable
to the abundant production of lymph are among the most unfavorable
to its development, i, e,^ to its complete and higher organization.
Even when the inflammation has ceased, and fresh lymph is not
formed, still, development is often prevented or retarded for want of
some necessary condition. The bloodvessels, long dilated, may remain
in a state of congestion, distended as if paralyzed, and filled with slowly
moving blood. In such a state of "passive congestion," so apt to
follow more acute attacks, development will not happen in even well-
disposed lymph. We have parallel facts in the tardy development of
granulations on the legs, in the healing of ulcers ; and how much this
depends on the defective movement of the blood is well illustrated by a
specimen"^ appropriate to an observation of Mr. Hunter's. It shows
three ulcers of the integuments of a leg ; they were all granulating,
and all healing ; but their progress in healing was inversely propor-
tionate to the hinderances of the blopd. The lowest of the three, that
most distant from the heart, and of which the vessels were subject to
the pressure of the highest column of blood, was least advanced in
healing ; while the uppermost of the three was most advanced, and was
nearly cicatrized.
But let us suppose all the conditions for development provided ; what
will now determine the direction or result of the process ? Into what
tissues will the lymph be formed ? Two chief things will determine
this : first, the general natural tendency of organizable lymph, pro-
duced in inflammation, is to form filamentous, i, e, fibro-cellular, con-
nective or fibrous tissue ; and, secondly, all lymph has some tendency
to assume, sooner or later, the characters of the' tissues in or near
which it is seated, or in place of which it is formed.
The natural tendency of lymph to the construction of fibro-cellular
or connective tissue, such as composes false membranes or adhesions,
and many permanent thickenings and indurations of parts, is shown by
the production of this tissue under all varieties of circumstances, and
in nearly all parts ; even in parts which, naturally, contain little or
none. Thus, it is found in the brain, and in glands, as in the testicle :
within joints, even where adhesions only pass from one articular car-
tilage to another ; in the adhesions and thickenings of the most diverse
serous membranes ; in the thickenings of the most diverse mucous ones.
And with all these, we have the corresponding facts in the healing of
wounds. All granulations, springing from what surface they may,
* Museum of the College, No. 26.
NBCES8ARY CONDITIONS. 249
tend, at least in the first instance, to the formation of filamentous
'tissue, such as we see uniting all parts in a stump ; and a large pro-
portion of subcutaneous injuries are repaired by similar tissue, what-
eyer parts may have been divided. And, sometimes, we may find
incomplete instances of this development where the lymph is not even
in continuity with any tissue, but floats free; as in ascites, or in
efiusions into joints.
But besides this general tendency, we may recognize in inflammatory
lymph a disposition to assume characters belonging to the part in which
it was produced ; so that, for instance, that about fibrous and ligament-
008 parts will be developed into peculiarly tough fibrous tissue ; that
about bone will become osseous ; that in the neighborhood of epithelium
will form for itself an epithelial covering ; and so on. I referred to this
fact in the last lecture, and suggested that this tendency of the de*
veloped lymph, to conform to the characters of the parts around it, is
probably due to the original and inherent quality of the lymph ; that
the material formed in the inflammation of each part partakes, from the
first, in the properties of the natural products of that part, and partakes
of them in an inverse proportion to the severity of the inflammation ;
because, the more the normal conditions of nutrition are deviated from,
the more will the material produced be unlike the normal product.
Besides, when the conditions are restored to the normal type, the or-
ganized product of inflammation will constantly approximate more and
more to the characters of the parts among which it is placed, or with
which it has acquired membership. As scars improve, t . e. gain, gradu-
ally, more of the characters of skin, so do false membranes, and the
like structures, formed by the organization of inflammatory lymph, ac-
quire, by their own nutrition and development, more nearly the charac-
ters of the parts with which they are connected. Thus, false membranes
in the serous cavities acquire a covering of epithelium exactly like that
which covers the original serous membrane, and their structure is that
of connective tissue; adhesions of the iris may become black, apparently
from the production of pigment-cells like those of the uvea ; thus, too,
m adhesions of the pleura, even when they are long and membranous,
pigment may be formed as in the pulmonary pleura itself ; and thus
many other inflammatory products are gradually perfected, till we may
eome to doubt whether they be of normal or of morbid origin, so com-
plete is the return from the aberrant action.
I will endeavor, now, to describe more particularly the transitions to
the seyeral tissues that may be formed from inflammatory lymph. I
need not, indeed, describe the minute changes of development ; for, as
the fibrinous and corpuscular varieties of lymph resemble very nearly
the two forms of reparative material, so (as far as they are yet studied),
their respective methods of development are equally similar. On
these points, therefore, I may refer to former lectures (pp. 139, e. s.,
156, 178, &0.) ; and, if it seem strange that disease should thus so
17
250 DEVELOPMENT OF LYMPH INTO
closely imitate health, let it be repeated, that this process of develop-
ment of the lymph is not disease. The lymph is, indeed, produced in
inflammation, but it is developed in health, when all the natural condi*
tions of nutrition are restored.
The instances are very numerous in which the inflammatory lymph,
following its natural tendency, becomes connective tissue. The general
forms which, in these instances, it assumes are (1) adhesions, where the
new-formed tissues is between free surfaces, and unites them ; (2) thick-
enings, where the formation is in the substance of membranes ; (8) in-
durations, with, or without, contractions, where it is in the substance of
organs ; (4) opacities of certain parts that were transparent.
The best examples of the formation of connective tissue from inflam-
matory lymph are in the adhesions, or false membranes, found after in-
flammation of serous or synovial membranes. In the former, especially,
the lymph is apt, in such favorable conditions as I have specified, to be
thus developed. In an acute peritonitis, or pleuritis, for instance, it is
usually, in the first instance, deposited in layers of uncertain thickness
on the opposed surfaces of the membrane. The condition of these
layers is variable. The lymph is sometimes grayish, half translucent,
compact, and laminated, consisting chiefly of fibrinous material, and
peculiarly apt for development : in other cases, it is yellowish, opaqae^
soft, succulent, or almost creamy, having a great preponderance of cor-
puscles, and being less fit for development : and between these forms
are many connecting varieties of appearance.
In the first instance, the connection of the lymph with the surface of
the serous membrane is, usually, such that it may be cleanly stripped
off". Its free surface presents great varieties ; it may be flocculent, or
villous, reticular, perforated, or nearly smooth. Commonly, at first,
the surfaces of the two layers (the visceral and parietal layers as they
may be called, after the portions of the serous membrane on which they
are severally placed) are separated by serous fluid, exuded, in various
quantity, with the lymph. But they may be, in parts, continuous, or
connected by bands or columns ; and, usually, when the inflammation
ceases, and such a state of circulation is restored as is favorable to the
organization of the lymph, the same state is equally adapted to the ab-
sorption of the superabundant fluid. In this case, the opposed surfaces
of the two layers of lymph are gradually brought into contact with
one another, and with portions of lymph which had floated in the fluid:
and now, as their organization proceeds, they are all united ; they be-
come continuous, and form "adhesions" between the opposite surfaces
of the serous membrane, whether these be the surfaces of adjacent organs,
as the abdominal viscera, or of any organ and of the cavity inclosing it»
as in the case of the testicle and tunica vaginalis.
The method, and the chief part of the plan, of the organization of
lymph in these cases, are, I believe, similar to those described in the
CONNECTIVE TISSUE. 251
healing of wounds by primary or by secondary adhesion ; and the gene-
ral results are the same. Various as are the forms and other conditions
of adhesions and false membranes (depending as they do on the relative
positions and mobilities of the parts that they connect), yet their struc-
ture, when complete, is, I believe, uniform. They consist of well-or-
ganized connective tissue, with which (perhaps only at a late period)
the elastic form of this tissue may be mingled: they possess abundant
bloodvessels, the chief of which are parallel to the direction of their
filaments; and their free surfaces are covered with an epithelium like
that of the membranes which they connect.
Connective tissue is formed in adhesions of synovial membranes as
well as of serous membranes ; and, probably, in the same manner. In
both cases, moreover, it is very usual for lymph to be exuded in and
just beneath the membrane, as well as on its surface; and this infiltrated
or interstitial lymph, becoming organized, produces thickening and opa-
city of the membrane. The coincident organization of the lymph, in
both positions, is well shown in the frequent instances of white spots in
the cardiac pericardium, with adhesions between the pericardial surfaces.
Such white spots, when completely formed, consist of new connective
tissue, exactly like that of the adhesions. It is by similar interstitial
exudation of lymph, and by its development into this kind of tissue,
that the frequent adhesions take place between parts which^ though
connected, should slide freely upon one another ; such as adjacent
tendons, &c. From this is derived a large share of the stiffness that
remains about injured joints ; the parts that should slide pliantly over
them are fixed by the new-formed interstitial connective tissue. So,
too, are formed the various morbid thickenings of parts ; as of pieces
of integument, capsules of joints, &c. But in many of these cases the
lymph retains very long its rudimental structures, and is, perhaps, on
this account, peculiarly apt to degenerate and permit absorption or the
ulcerative process. I know no better example, for microscopic exami-
nation of interstitially deposited lymph, than an indurated chancre:
but I have never found one in which the lymph-cells had reached a
farther development than the elongated caudate form. When the exu-
dation is interstitial in any of the more compact forms of connective
tissue, as in ligaments, capsules of joints, and the like, the lymph is
developed into the denser kinds of connective tissue. The best exam-
ples of it are in the laminated and nodular thickenings of the capsule
of the spleen, or the thickening and induration of the periosteum, or
the capsule of the hip-joint in chronic rheumatic arthritis. In all these
cases, the new material is derived from repeated, but not acute inflam-
mations ; therefore, probably, though excessive, it is not widely difierent
from the normal material for nutrition ; and, the conditions for nutrition
being little disturbed, it is developed into the exact likeness of the ori-
ginal texture, with which it is intermingled and confused.
As the connective tissue formed from inflammatory lymph becomes
252 DEVELOPMENT OF LTMPH INTO
more perfectly organized, it is prone to contract: imitating the con-
traction already described in granulations and scars (p. 173). Hence,
in part, the contraction of the wall of the chest after plenrisy, and the
various displacements and deformities of organs that have become ad-
herent to adjacent parts: hence, in part also, the contractions of
inflamed organs, as of the liver in cirrhosis : hence, too, an addition to
the rigidity of joints when the parts around them have been inflamed;
and hence, with yet greater mischief, the contractions of the thickened
valves, and tendinous cords of the heart.
The elastic form of connective tissue is sometimes abundantly pro-
duced in the adhesions developed from inflammatory lymph. I have
not seen it except in such as are completely organized ; and I think it
is, in this case, as in the formation of scars, a late production (see p.
174). I believe, also, with Virchow,* that its formation depends, in
some measure, on the membrane that is inflamed; pleural adhesions
being most favorable to it. In these it is often abundant ; its principal,
but always slender, filaments lying in the same general direction as
those of the white fibrous tissue.
Adipose Tissue may be formed, if not directly from inflammatory
lymph, yet in the connective tissue of completely organized adhesions.
I think it is not often so : but, lately. Dr. Eirkes found a lung of which
all the anterior part was covered with well-organized false membrane;
and in part of this was a quantity of perfect adipose tissue, more than
four ounces in weight.
Epithelium I have already mentioned as covering the surfaces of
well-formed adhesions. It is not rare to find, in inflammation of serous
membranes, recent lymph-cells presenting many characters indicative
of development towards epithelium ; flattened and enlarged, and having
circular or oval clear nuclei : and it may be developed in the form of
epidermis on the surface of granulating sores.
Bone is often formed from inflammatory lymph. It may appear as
a late transformation of lymph that has been organized into perfect
fibrous tissue ; as in the osseous plates that are sometimes found in the
false membranes of the pleura, or in the pericardium. In most of these,
however, there is not true bone, but an amorphous deposit of earthy
matter, which is imbedded in the fibrous tissue, or which (as Rokitansky
holds) is the residue of the degenerated and partially absorbed tissue.
The proper condition for the transformation of lymph into bone is
that in which the exudation takes place in an inflammation seated in.
the bone itself, or else, in or near the periosteum. Such inflammations
* Verhandl. der Phys.-Med. Gesselschaft in WOrzburg, 1850, p. 142. He describes her©
a peculiar thorny or dentate structure oAen presented by the elastic filaments in old
adhesions.
BONE. 258
have been called '^* ossific ;" and the Museum of the College, like every
other, abounds with specimens of their various results.
There is a great lack of minute observations respecting both the
characters of the lymph exuded in inflammations of bone or perios-
teum, and the methods of its ossification. Such as have been made,
indicate, as might be expected, a close resemblance to the processes
described in the repair of fractures* (p. 177, et seq.). The lymph pro-
duced in moderate inflammation, and therefore likely to ossify, is, at
first, according to Rokitansky, a dark red exudation, like gelatine,
which, being gradually decolorized, becomes white, and at the same
time acquiring firmness, becomes like soft flexible cartilage, and then
like ruddy succulent bone. But though it be like cartilage, I suspect
that cartilage is very rarely, if ever, formed in inflammation of bone ;
for it seems to be formed in the repair of fractures only when the con-
ditions are more favorable than they are likely to be in any inflamma-
tions. Probably the lymph is more or less developed towards the fibrous
tissue when it ossifies ; and, as in the repair of fractures, so here, we
may believe that ossification may be postponed till the fibrous tissue is
quite formed, or that it may ensue in the rudimental state of the tissue,
whether in a nucleated blastema, or in cells like those of granulations.
It would be hardly possible to explain, without illustrative specimens,
all the various appearances of bone new-formed in or after inflamma-
tions. It may be produced in the very substance of compact bone, after
the softening and expansion of the original tissue which occur in the
earlier parts of the inflammatory process, and to which I shall have
again to refer. Or, it may be produced in the medullary or cancellous
tissue ; and here, commonly, it appears as a gradual thickening of the
minute cancellous lamellae and fibres of bone, which, as they increase,
gradually exclude the proper structures of the diploe or medulla, and
finally coalesce into hard solid bone.
But, by far the most common seat of the formation of new bone, and
that in which it is almost always found when it exists in either of the
former situations, is on the surface, between bone and periosteum, or
eyen in the periosteum itself. Here it forms the various growths to
which the general term Osteophyte has been given. In a series of speci-
mens of common inflammation of bone or periosteum, it is not difficult
to trace the changes of construction of the new bone, by which, like
that formed in a process of repair, it gradually approximates to con-
formity with the bone on which it grows. f
At first, it is, when dried, light and friable, with a close filamentous,
* KSmUd, MUUer's Archiv, 1845, p. 60 ; Rokitansky, ii, p. 172 ; Virchow, in his Archiv,
i>M35.
t Aof large Museum will supply such specimens. Those in the College of Surgeons
^'e Qioutely described in the Catalogue, vol. ii, p. 83, e. s^ and vol. v, p. 43, e. s. ; those at
^ Biitholomew*8 may be studied through the Indices, p. 1 and 57. Even different parts
^> liiigle specimeo will show much of what is described.
254 DEVELOPMENT OF LYMPH:
velvety texture, and a smooth surface, gradually rising from that of
the surrounding healthy bone. As it increases in thickness it becomes
longitudinally grooved, as if lodging bloodvessels, passing, through it,
from the periosteum to the old bone. Then, as fresh formations of new
bone take place, they assume the form of nodules and thick plates, laid
over the longitudinal grooves, and leaving large apertures for the pas-
sage of bloodvessels. Such plates, like nearly all bone new-formed in
disease, present, at first, a porous surface and a finely cancellous lung-
like texture. But, gradually, in whatever form, the new bone tends to
become harder and heavier ; the apertures that made its surface porous
gradually diminish till they are obliterated, and thus the new bone,
while still cancellous within, acquires a compact external layer, and
becomes more firmly united to the bone beneath it. The process of in-
duration continuing, the new bone acquires throughout a hard compact
texture : its outer surface, no longer porous, becomes nearly as smooth
as that of the old bone ; its color also changes to that of the old bone ;
and, finally, the two unite so closely that the boundary line between
them can hardly be discerned.
Such is the gradual assimilation of the inflammatory product to the
characters of the normal structure from whose disease it issued : a pro-
cess peculiarly worth studying in the bones, because in them, more than
in any other tissue, the changes can be leisurely examined. Those which
I have described occur in common inflammations : such, e, g,, as follow
injuries, or exist in the neighborhood of necrosis, or ulceration, or foreign
bodies. They are generally observed, also, in specific inflammations of
bone ; but, among these it is worth observing how characteristic of differ-
ent diseases are certain formations of the new bone. The pustules of
variola, or the vesicles of herpes, are scarcely more characteristic of
those diseases, than are the hard nodules of cancellous bone, clustered
about the articular borders of bones that have been the seat of chronic
rheumatism ; or the porous, friable, dirty, and readily ulcerating thin
layers formed on the shafts in syphilis.*
Cartilage^ I have said, is probably not formed in inflammatory lymph
in the process of its ossification. Neither does it appear to be formed
in the more acute inflammations of articular cartilage : but, we must
not exclude it from the possible developments of inflammatory products,
while we remember the observations of Mr. W. Adamsf respecting the
enlargements of the ends of bones in chronic rheumatic arthritis. In
these, which are marked by such formations of new bone, and such
thickenings of fibrous tissue, as we constantly ascribe to inflammations,
there is manifest increase of the articular cartilage, and a subsequent
ossification both of that which is new formed, and, more slowly, of that
* As in Nos. 572, 628, and others, in the College Museum,
f Trans, of Pathol. 8oc. of London, vol. iii, 1851.
BLOOD AND BLOODVESSELS. 255
which normally covered the head of the bone. The early conditions of
the increase of the cartilage are not traced : but that it depends on in-
flammation, rather than on true hypertrophy, is probable, both from the
concurrent signs and results of inflammation, and from the new carti-
lage falling short of the perfect characters of the old; for it has a
fibrillated intercellular substance, and scattered nuclei, and is prone to
ossification.
It remains that I should describe the adjunct structures of organized
inflammatory lymph. But this may be briefly done, because the account
of the formation of new bloodvessels in granulations and other repara-
tive materials might, I believe, be transferred hither (from p. 159).
The question is, indeed, often raised, as in the corresponding instance
of granulations becoming vascular, whether the bloodvessels are formed
entirely of the material of the lymph, and, as it were, by its own power
of development, or whether they are outgrowths from adjacent natural
or original vessels, which, as the expression is, shoot out into the lymph.
I think it nearly certain, for the following reasons, that the lymph
forms neither vessels nor blood, but receives those that are projected
into it from the parts on or in which it is placed.
1. The direct observations supposed to prove that blood is formed in
inflammatory lymph are very liable to fallacy, through the facility with
which blood may be accidentally mixed with the lymph, in consequence
of hemorrhage during life or after death, or in the preparation of the
specimens. Where these sources of fallacy have been avoided, I have
never seen anything suggestive of a transformation of lymph into blood.
2. The development of blood from tissue-cells is limited, naturally,
to the earliest period of embryo-life, as if it needed the greatest amount
of force for development ; afterwards, blood is not formed except through
a long process of elaboration, and with the aid of many organs. Its
formation, therefore, in the mal-conditions of inflammation, is very im-
probable.*
3. In no specimen of inflammatory lymph have I seen appearances of
transitions from lymph-cells to blood-cells, such as we may see in the
lymph of lymphatics, both before and after it is poured into the blood-
Tessels.
4. Neither in any lymph have I seen appearances of such stellate
cells as the interstitial bloodvessels of the early embryo are formed from ;
nothing comparable with them has ever come into view.
5. In the formation of vessels for granulations and the walls of
chronic abscesses, all is favorable to the belief that they grow up
* It should be stated, however, that Billroth, in his researches into the mode of formation
of bloodTessels in granulations, has described and figured appearances which have led him
lotDppote that here, as in the origin of the first blood-corpuscles in the embryo, the contents
of Kxne of the granalation-cells may form new blood corpuscles, whilst the cell-membranes
nay assist in the formation of the walls of the new bloodvessels.
DEVELOPMBNT OP LYMPH IHTO
from the bloodvessels of the adjacent parts ; and there are do BtroiV
tures to which the lymph bears so close analogy as it does to these, or
to which it is so likely to be conformed in the production of its Tessels.
On the whole, therefore, although direct observations are wanting, I
think we may conclude that all the vessels of inflammatory lymph are
formed by outgrowth from adjacent vessels, as in the process of repair,
and that through these vessels, not by its own development, it derives
its supply of blood.
In the first instance, the bloodvessels of lymph appear to be usually
very numerous and thin-walled ; therefore easily bursting, or dilat^
by congestions during life, or in the attempt to inject them after death.
The College collection contains an extremely beautiful specimen of soft
recent lymph from the pericardium
of a Cheetah, the vessels of which,
injected by Mr, Quekett, appear
as numerous and close-set as those
of some of the more vascular mu-
cous membranes. They present
occasional slight and gradual di-
latations, especially when they
branch or anastomose.
But after an uncertain time, as
the lymph becomes more highly
organized, so its vessels waste and
diminish in number; and while it
acquires the proper structure of
the connective tissue, so it descends
to the low degree of vascularity of
that tissue. The vessels of false
membranes, as represented here
(Fig. 34), from an instance in which they were naturally injected with
blood, are usually rather wide apart, long, slender, and cylindriform.
In all these particulars they differ from those of more recently vascu-
larized lymph ; und their changes are, in these respects, parallel with
those of the vessels of granulations during the gradual formation and
perfecting of scars.
Perhaps the most perfect instance of the conformity with the natural
tissues of the body to which the developed lymph can attain, is mani-
fested in its acquiring a supply of lymphatic vessels. We owe the
knowledge of the lymphatics of false membranes to the masterly skill
of Professor Schroeder van der Kolk, whose preparations of them are
described and represented by his pupit, Dr. de Lespinasse.* In Fig. 35,
jm, 8vo. Davenlris, 1843, flgt
adlieaion between the liver Bnd
teen an ovariBn lumnr wiJ the
■1 CancereuM*, p. 40.
r itiji-clion of these in adbesiona bel>
riibetl by Leberl: Tnu6 de* Maladi
LYMPHATICS. 257
copied from one of his platea, beantifnl networks of lymphatics, witli
their eharacterietic be&ded
forms and abundant anasto-
mosee, are shown traversing
adhesions extending between
two lobes of a lung ; while yet
closer networks are seated in
the thickened and opaque- '
white substance of the pleura,
or of false membrane covering
it, beneath the adhesions.
It seems to be in only the
most perfect state, and when
bloodvessels have long exist-
ed, that lymphatics are formed
in false membranes. In recent
lymph Schroeder v. d. Kotk has never succeeded in injecting any ; and
we can only suppose that they are, like the bloodvessels, produced by
oatgrowth from the lymphatics of the membrane with which they are
eoonected.
Virchow* has twice seen nerve-fibres in adhesions. In one case, two
fine nerve-fibrea passed through an adhesion of the pleuree; in the
other, a single fibre extended into, but not through, an adhesion be-
tween the liver and diaphragm.
The time in which these complete developments of lymph may be
accomplished must vary so much, according to the circumstances of the
bflammation, that perhaps no reasonable estimate of it can be made.
The experiments of Villerm^ and Dupuytrenf upon dogs assign twenty-
one days as the earliest time in which new vessels are formed, but I am
disposed to agree with Dr. Hodgkin, that a shorter time is sufficient.
On the other hand, I am sure that the supposition of their being formed
m one or two days is incorrect. The principal case in support of this
opinion is that recorded by Sir Everard Home ; but the specimens pre-
served in the College MuseumJ show that be was deceived as to the
true natnre of the case. He Bays§ that he operated for strangulated
btrnia in a man, and found in the sac a portion of ileum, which was
Withy, except in that its vessels were turgid with blood. The patient
died twenty-nine hours after the operation j and on examination "seve-
r»l small portions of exuded coagulable lymph' ' were found adhering to the
* VOizbarg Terhandliingsn, i, 144.
t Quoted by Dr. Hodgkin, in bi> Leotuiei on the Morbid Anatomjr of the Sprout Mem-
^uiet,p,4'i,
X Sat. 81 ■ml 83 in lbs PatbologicBl Museum.
} In hit DiMoititioa on Put, p. 41. The whole anie ia given in the College Catalogue,
Wli,p.37.
258 DBGBNEBATIONS OF LTMPH.
intestine that had been protruded. When the vessels of the intestine
were injected, the injection passed into vessels in all these portions of
supposed lymph, each '^ having a considerable artery .... and a re-
turning vein." Sir Everard Home, therefore, concludes "that the
whole operation of throwing out coagulable lymph, and supplying it
with bloodvessels, after it had become solid, was effected in less than
twenty-four hours."
Now, one of these specimens was figured by Mr. Hunter,* " to show
a small portion of coagulating lymph which is supplied with
vessels;" but neither here, nor in his manuscript catalogue, does he
allude to a probability of the vessels having been formed in twenty-four
hours, although, had he believed it he would scarcely have failed to
record it.f An examination of the specimens shows that the small,
shred-like portions of membrane, attached by little pedicles to the in-
testine, have not the appearance of recently coagulated lymph, but are
fully organized, with traces of filaments and fat-cells. They are also
very regularly disposed, at distances of from half an inch to an inch
from each other, and are nearly all placed in two rows on each side of
the intestine, about half an inch from the attachment of the mesentery,
like very minute appendices epiploicse, such as are occasionally met
with on the coats of the small intestine. Whether they be such appen-
dices or not, it is in the highest degree improbable that they were
formed after the operation ; especially since they are too minute and
delicate to have prevented the intestine from exhibiting, when exposed
in the sac, the natural polished appearance of its surface.
I am not aware of any other ease adapted to prove the earliest period
at which bloodvessels may be formed in lymph. Serous surfaces may,
indeed, become adherent in twenty-four hours, but this does not imply
vascularity of the lymph between them ; it is simply adhesion by the
coaptation of the intermediate lymph.
LECTURE XVI.
DEGENERATIONS OF LYMPH.
Having given, in the last lecture, a general history of the chief de-
velopments of the lymph exuded in the inflammatory process, I propose
now to tell a corresponding history of its degenerations ; and herein to
describe what appear to be the transitions, from the ordinary forms of
lymph in its primary state, its fibrine and its corpuscles, to those many
* Works; pi. xxi, fig. 2.
f In the treatise on the Blood (Works, vol. iii, p. 350) he speaks of nine days as a short
time for the complete organization of adhesions. *
DEGENERATIONS OF THE FIBRINE OF LTMPH. 259
lower forms enumerated as molecular and granular matter ; as pus-cells,
granule-cells, inflammatory globules, and the rest.
I said that, for the development of lymph produced in inflammation,
it is requisite that the inflammation shall have ceased, and the condi-
tions of healthy nutrition be restored. In the failure of this event, if
the inflammation continue, or the due conditions of nutrition be in any
way suspended, then, instead of development, degeneration will occur,
with more or less rapidity, according to the original character of the
lymph. And this may happen in any of the stages of formation which
I described in the last lecture : it may happen alike to the rudimental
fibrine, or to the earliest lymph-cell, or to either, in any part of its
progress to complete development.
The following appear to be the chief degenerations of the fibrinous
part of lymph, or of the materials derived from its earliest stages of
development, whether in the purely fibrinous, or in any of the mixed,
forms of lymph :
1. It may wither ; wasting, becoming firmer and drier, passing into a
state which Rokitansky has designated homy. One sees the best ex-
amples of this change of fibrine in the vegetations on the valves of the
heart, or in the large arteries, when they become yellow, stiff", elastic,
and nearly transparent. The fibrine may, in this state, show no marks
of development into tissue, but may have all the simplicity of structure
of ordinary fibrine, being only drier and more compact. A nearly
similar character is acquired when lymph is deposited over a lung which
is extremely compressed in empyema, or in hydrothorax. The tough
dry lymph that here forms the grayish layer over all the lung is not
always developed, though it may adhere firmly : it may be withered,
wasted, and dried (as the lung itself may be), apparently in consequence
of the compression.
2. The fibrine of lymph is subject to a degeneration which we may
compare in many respects with fatty degeneration, or more closely,
with the changes by which lymph-corpuscles are transformed into those
of pus, with which changes, indeed, this is commonly associated in the
mixed forms of lymph. In the solid parts of eff^usions that are found
in the lower forms of inflammation, or in very unhealthy persons, the
fibrine of the lymph is usually not clear and uniform and filamentous,
but rather opaque or turbid, nebulous or dotted, presenting just such
an appearance as marks the earliest stages of fatty degenerations in
the muscular fibrils. In such lymph, also, one sees, not unfrequently,
minute, shining, black-edged particles, which we may know to be drops
of oil; while some general alteration in the composition of the fibrine
is shown by its not being made transparent with acetic acid. In all
such cases as these the fibrine is very soft, and easily broken ; it is
devoid of all that toughness and elasticity which is the peculiar charac-
teristic of well-formed fibrine ; and by breaking it up, one may see the
meaning of what one so often finds in the lowest forms of inflammatory
L
260 DEGENERATIONS OF THE FIBBINE OF LTMPH.
exudation, such as occur in erysipelas and typhus; namely, films and
fragments of molecular and dotted substance, floating in fluid that is
made turbid by them, and by abundant minute molecules and granules
and particles of oily matter. These represent the disintegration of
fibrine that has degenerated after clotting, or has thus solidified in an
imperfect coagulation. Of such changes, also, an excellent instance is
presented in the softening and disintegration of clots within the heart,
which Mr. Gulliver* first described. These, indeed, or any of the in-
stances of the apparent suppuration within clots in the bloodvessels,
might be studied for the illustration of the corresponding changes in
inflammatory lymph ; especially, in relation to the likeness which, in
both cases, the degenerate fibrine bears to the molecular matter in the
thinner and more turbid kinds of pus.f
We have examples of numerous varieties of this degenerate and dis-
integrated fibrine exuded in inflammation. It is a principal constitu-
ent of most of what has been called ^^ aplastic lymph," in inflammation
of the serous membranes. Similar fibrine occurs, mingled with mucus,
in the severer inflammations of the mucous membranes. And to the
same source we may trace much of that molecular and granular matter
which is usually mingled with all the less perfect forms of pus : e. g.
with that formed in the suppuration of chronic inflammatory indura-
tions ; with the variously changed corpuscles of " scrofulous matter ;"
or with the granule-cells, and other corpuscles of pneumonia, and the
like inflammations.
The general characters of the materials here described, and the coin-
cident changes ensuing in the corpuscles that may be mingled with the
fibrine, make it probable that the changes are of the nature, of fatty
degeneration occurring in the fibrinous lymph. Analogous to these
changes are those which take place in animal substances when trans-
planted to parts with which they have normally no organic connection.
Thus R. WagnerJ has shown that a testicle, when engrafted into the
peritoneal cavity, goes through the process of fatty degeneration, and
that the same change takes place in the crystalline lens, bits of muscle,
and even portions of boiled white of egg when similarly treated. That
these changes are due to an actual conversion of the transplanted sub-
stance into fat appears to be proved by the observations of Michaelis,§
who has noticed that the production of ammonia is an accompaniment
of the transformation.
But when, as I have said elsewhere (p. 172), we see how a large mass
of inflamed hard substance will become fluid, as it suppurates, and this
with scarcely any, if any, increase of bulk, we may believe that another
* Medico-Chirurgical Transactions, vol.xxii, p. 130.
t We ought, doubtless, with Mr. Gulliver, to regard the corpuscles found in these casM
of soAened clots within the heart as blood-corpuscles retained in the clot, modified by stag-
nation and concoction.
X Nachricht der Getting. Acad. 1851. § Pr^er. Vierteljahr. Schrift, 1853.
DBaBNERATIONS OF THE FIBRINB OF LYMPH. 261
change ensuing in the fibrine is that which I called liquefactive degene-
ration (p. 89). In such a swelling, we may be nearly sure there is
coagulated fibrine, both from the general circumstances of the inflam-
mation, and because neither corpuscles alone, nor fibrine in the liquid
state, would give such hardness. The suppuration, therefore, if without
increase of bulk, can hardly be explained, except on condition of the
fibrine, which had solidified, becoming again liquid. The occasional
liquefaction of clots out of the body'^ makes it more probable ; but I am
not sure that it can be proved by any more direct facts.
A point of some practical importance is connected with these forms
of degeneration of lymph, whether affecting fibrine or corpuscles. When
the fibrine has withered and become dry, it is probably put out of the
capacity of being further developed, and is rendered passive for further
harm or good, except by its mechanical effects. But the fatty and
liquefactive degenerations may be yet more beneficial in that they bring
the lymph into a state favorable to its absorption, and therefore favor-
able to that which is termed the '' resolution'' of an inflammation in
which lymph has been already formed. I suppose it may be considered
S8 a genera] truth, that the elements of a tissue cannot be absorbed so
long as they retain their healthy state. There is no power of any ab-
sorbent vessels that can disintegrate or decompose a healthy portion of
the body : for absorption, there must, in general, be not only an absorb-
mg power, but also a previous or concurrent change, — as it were a con-
sent, in the part to be absorbed ; so that it may be reduced (or, rather,
may reduce itself) into minutest particles, or may be dissolved. And
this change is probably one of degeneration, not death, in the part ; for
dead matter is usually rather discharged from the body than absorbed.
Now such degeneration of the fibrine-products of inflammation as I
have described, brings them into a state most favorable for absorption ;
mdeed, one may see in lymph thus changed many things which, in
regard to the fitness for absorption, make it parallel with chyle. f Of
such absorption of fibrine we may find many instances. In rheumatic
iritis we may believe the lymph to be fibrinous ; but we see its complete
tbflorption taking place ; and the observations of Dr. Kirkes on the
Ttrity of adhesions of the pericardium, in comparison with the frequency
of pericarditis,^ may be in the same manner explained. In rheumatic
pericarditis we may be sure fibrine is exuded ; and the observed friction-
sound has, in some cases, proved its coagulation ; yet in these cases,
then death occurred months afterwards, scarce a trace of fibrine was
found in the pericardium : it had been absorbed, and the degeneration
I have been describing was probably the preparation for its absorption.
* Af in cases by Nasse and De la Harpe, quoted by Henle, in his ZeitschriA, B. ii, p. 169.
^ tlso Viicbow on the same subject, in the same ZeitschriA, B. iv. Henle refers to this
*iBs liqaefiKStioo the changes that ensue in emitted semen.
t See also the ingenions contrast of the progress of chyle and the regress of pus drawn
^Geiber, in his Allgero. Anatomic, p. 49.
I Medical Oasette, April, 1849.
262
DEGENERATIONS OF THE FIBRINE OF LYMPH.
3. I am not aware of any direct proof of the calcareoas degeneration
ensuing in the fibrinous part of an inflammatory exudation ; but we have
the strongest evidence from analogy for believing that this change may
be a frequent one. For there are numerous instances of calcifications
of fibrine within the vessels : as, e. g, in the ordinary formation of phle-
bolithes from clots of blood, in the branching and irregular pieces of
bone-like substance found in obliterated veins, and in the lumps and
grains of substance like mortar imbedded in fibrinous deposits on the
heart's valves. We can, therefore, hardly doubt that the fibrine, even
before development, may take part in formations of earthy matter in
inflammatory products ; but the calcareous degeneration seems much
more frequent in purulent fluids, and in the later developments of
lymph.
4. Lastly, we have examples of the pigmental degenerations of
fibrinous lymph in the various shades of gray and black which often
pervade the lymph formed in peritonitis, and which are produced, not
by staining or discoloration of the blood by intestinal gases, but, accord-
ing to Rokitansky, by the incorporation of free pigment-granules.
Such appear to be the degenerations of the fibrine of inflammatory
lymph : such, at least, are the changes in it which we may refer to de-
fects in its power or conditions of nutrition, because they correspond
with changes that may be traced in the gradual degenerations of old
age. I need hardly say, that it is chiefly by such correspondence that
we can interpret them ; for when we find them, it is often beyond our
power to tell, by direct observation, whether, or in what way, the con-
ditions of nutrition were defective.
The corpuscular constituents of lymph, in any of their stages of de-
velopment, may retrograde, and present degenerations corresponding
and usually concurrent with those which I have just described.
1. Their withering is well seen in some forms of what is called scro-
fulous matter, such as occur in chronic and nearly stationary scrofulous
enlargements of lymphatic glands. In the dull ochre-yellow colored,
and half dry material, imbedded in such glands, may be found abundant
cells, such as are sketched in Fig. 36. They are collapsed, shrivelled.
Fig. 36.
•IPr
^':\
~^.}
i
1/
wrinkled, glistening, and altogether irregular in size and form. One
might suppose them to be the remnants of pus dried up, or the corpus-
cles of chronic tuberculous matter, if it were not that among them are
some with nuclei shrivelled like themselves, and some elongated and
BEOBNERATIONS OF THE CORPUSCLES OF LYMPH. 263
attenuated, which are evidently such as withered after they had been
developed into the form of fibro-cells; into which form it is certain
that neither pus-corpuscles nor those of tubercle are ever changed.
These are the best examples of withered lymph-corpuscles ; but they
may be also found. in the pus of chronic abscesses, especially, of course,
in that of such abscesses as ensue by suppuration of lymph-deposits
like those just referred to. It may be hard, sometimes, to say whether
corpuscles in these cases may not be pus-corpuscles shrivelled up : but
on the whole, 1 am inclined to believe that the shrivelled corpuscles of
the pus of chronic abscesses are usually derived from the lymph, in
which, having withered, they had become incapable of further change.
2. The fatty degeneration of lymph-cells is shown in their transition
into granule-cells — the inflammatory globules of Gluge. We owe the
first demonstration of this to the excellent observations of Reinhardt,*
who has also shown how, by similar degenerations, corresponding forms
of granule-cells may be derived from the primary cells of almost all
other, both normal and abnormal, structures. f
This method of degeneration appears peculiarly apt to occur in the
inflammations o^ certain organs ; as, especially, the lungs, brain, and
spinal cord ; but it may be found occasionally prevalent in the lymph
of nearly all other parts, and in the granulations forming the walls of
abscesses or of fistulas. It may occur alike in the early forms of lymph-
cells, and after they have already elongated and attenuated themselves,
as if for the formation of filaments, and after they have degenerated
into pus-cells. The changes of transition (as shown in fig. 37) are,
briefly, these : The lymph-cells, which may have at first quite normal
characters, such as I have described (p. 234), present a gradual increase
Fig. 87.
of shining, black-edged particles, like minute oil-drops, which accumu-
late in the cell-cavity, and increase in number, and sometimes in size
also, till they nearly fill it. The fatty nature of these particles is
proved by their solubility in ether : and their accumulation is attended
with a gradual enlargement of the cell, which also usually assumes a
more oval form. Moreover, while the fatty matter accumulates, the
rest of the contents of the cell become very clear, so that ajl the inter-
* Traabe'8 Beitrage, B. ii, 277.
t ObeerTations similar to part of those of Reinhardt were made independently by Dr.
Andrew Clark. (Medical Gazette, vols, zlii, xliii.) See also Dr. Gairdner's description of
the formation of granule-cells from epithelium-cells in pneumonia (Contributions to the
Fubology of the Kidney, p. 20) j and the list of references, p. 119.
264 DEGBNEBATIONS OF THE CORPUSCLES OF LTMPH.
spaces between the particles are quite transparent ; and, coincidently
with all these changes, the nucleus gradually fades and disappears, and
the cell-wall becomes less and less distinct.
I need hardly say, that, in these particulars, the changes of the
lymph-cells (which may also occur when they have been already de-
veloped into the form of fibro-cells), correspond exactly with those of
the fatty degenerations observed in the cells of the liver or kidney, or
in the fibres of the heart. There can be hardly a doubt of the nature
of this process : and it presents an important parallel with the similar
changes described in fibrine. For, we may observe, first, that where
this degeneration is apt to occur in lymph, it is least likely to be de-
veloped. A proper induration and toughening of the lungs and brain,
such as might happen through development of the products of inflamma-
tion, is extremely rare; it is rarely seen, except in the scars by which
the damages of diseases are healed. And, besides, this degeneration is a
step towards the absorption of the lymph ; for commonly we may trace
yet later stages of degeneration in these granule-cells. They lose
their cell-walls, and become mere masses of granules or fatty particles,
held together for a time by some pellucid substance, bht at last break-
ing up, and scattering their components in little clusters, or in separate
granules.
Thus, if at no earlier period of their existence, or after no fewer
changes, the lymph-corpuscles may pass into a condition as favorable
for absorption as is that of the fibrine when similarly degenerate and
broken up : and such as this, we may believe, is a part of the process
by which is accomplished that " clearing up'* of parts indurated and
confused in inflammation, and, especially, that of the solidified lung,
which is watched with so much interest in pneumonia.
3. Calcareous degenerations of the lymph-cells appear in cases, such
as Henle* refers to, in which granule-cells are composed not wholly of
fatty matter, but in part also of granules of earthy matter. In this
combination they correspond with a common rule ; for the fatty and
earthy degenerations are usually coincident : they are combined in the
advanced stages of the degenerations of arteries, and may be said to
have their normal coincidence in ossification.
4. Of the pigmental degeneration of lymph-cells there are, I sup-
pose, examples in the black matter eff'used in peritonitis : but the best
examples are in the cells in bronchial mucus, to which I have already
referred (Fig. 33).
The most frequent degeneration of inflammatory lymph is into pus.
It may ensue in nearly all the cases in which lymph is placed in condi-
tions unfavorable to its development ; as in the persistence of inflamma-
tion, or in exposure to air, or in general defects of vital force. It
* In his ZeitschriA, B. ii.
INFLAMMATORY SUPPURATION. 265
affects alike the fibrinous and the corpuscular parts of lymph. For
although we do not call any liquid '^pus,'* unless it have the charac-
teristic pus-corpuscles, yet the materials of degenerate fibrine are com-
monly mixed with these ; and indeed many of the varieties of the pus
formed in inflammations owe their peculiarities to the coincident de-
generations of the fibrine.
The changes which seem to prove the transformation of inflammatory
ijmph into pus correspond very nearly with those already cited (p. 170)
concerning the similar relations of granulations to pus in the process of
repair. But a few may be mentioned here :
1. The fluid of such vesicles as those of herpes, is, in the first in-
stance, a pure inflammatory lymph, containing corpuscles which might
be taken as types of the lymph or exudation-corpuscles, and which may
be as easily distinguished from any cells of pus, as the cells of well-
formed granulations may be. If we watch these vesicles, we see their
contents not increased, — rather, by evaporation, they are diminished ;
but the lymph is converted into pus, and pus-cells are now where lymph-
cells were. And the change may ensue very quickly : I think I have
known it accomplished in twelve hours at the most.*
2. In like manner, as I said before (p. 172), when we watch the pro-
gress of an abscess, we may find one day a circumscribed, hard, and
quite solid mass, and in a few days later the solid mass is fluid, and
this with little or no increase of bulk. Now, the solidity and hardness
are due to inflammatory lymph ; the later fluid is pus, and the change
is the conversion of lymph into pus.
3. As in common suppuration of a granulating wound, the granula-
tion-cells appear to be convertible into pus-cells, superficial cells being
detached in pus, while deeper ones seem as if developing into filaments ;
and as in worse formed granulations, the cells are often by no charac-
ters, except by their forming a solid tissue, distinguishable from pus-
ceils ; so, in an inflamed serous membrane, pus-cells may float in the
fluid, such as cannot be distinguished from cells in the vascularized
lymph that lines the cavity. In the fluid exudation, and in that which
w solid, the same forms may be found ; though, by comparison, we may
be able to trace that in the former none of the cells were being developed,
»nd many were proceeding beyond the degeneration to which any had
attained in the latter.
4. One may see the same conversion of inflammatory lymph into pus
thus illustrated. An amputation through the thigh was performed when
all the parts divided were infiltrated with lymph, eff'used in connection
with acute traumatic inflammation of the knee-joint. Next day pua
flowed freely from the wound. Now, in amputation through healthy
tissues, free suppuration does not appear till after three or four days :
* It may be that the lymph and pus-cells formed in these cases are derived from the
Doclei of the cells of the deeper epidermal layers. See note, p. 235.
18
266 INFLAMMATORY SUPPURATION.
the pus here seen must have been fonned by the conversion of the in-
flammatory lymph previously infiltrated in the divided tissues. Similar
facts may be less strikingly observed in any wound.*
* Since the delivery and publication of these lectures, much has been written on the sub*
ject of suppuration and the origin of pus, which tends to throw a new light on many of the
pathological changes discussed in this and others of these lectures. It is by Professor Vir-
chow, and the school of pathologists of which he is the chief expositor, that most of the in-
vestigations have been made, which render necessary a modification of some, at least, of our
former views on this question. From a very extended series of observations conducted on
most of the textures and organs of the body, it would appear, that a free exudation of lymph
into or amongst them is not an essential preliminary to the process of suppiiHition, and that
when such an exudation does take place, the pus-ceils do not arise in it by any mere aggre-
gation of granules and visible molecules — by a spontaneous free cell formation — as is some-
times described, but that the pus proceeds from peculiar formative changes in the cellular
and nuclear elements of the parts themselves. To render such a theory at all probable, it
was necessary to show that a wide-spread diffusion of cellular or nuclear structures existofl
in the midst of the (bxtures in their completed state. These had long been known, in tivkny
localities, as muscle, nerve, cartilage, epithelium, and, as was pointed out by Professor Grood*
sir, in bone itself. It is in the connective tissue, however, in its various forms and modifi-
cations, that they have of late years been particularly recognized, and it is in their relations
to this important texture that the observations of Vircbow especially apply. For, from the
extensive distribution of the connective tissue in all parts of the body, not merely in its spe*
cial forms of tendons, ligaments, fasciae, aponeuroses, but from its relations to bone and ca^
tilage, from its presence in the muscular and nervous textures, in skin, mucous, and serous
membranes, from its forming a more or less continuous framework in which the vascular,
tubular, and epithelial elements of the various glands are imbedded, it constitutes undoubt-
edly one of the most important tissues of the body, and supplies us with a source from which
such cellular, or nuclear, structures may be derived.
Many experiments and observations have now demonstrated that when pus forms in a
deep-seated part it is preceded and accompanied by changes in the cellular elements of the
connective tissue of that part, and, in some cases, even in the nuclei of the muscular and
nervous tissues also. These changes consist in an elongation and subsequent division of the
nucleus, so that, where but a single nucleus existed in the normal state, now crowds may be
observed. In the course of time these assume the appearance of pus-corpuscles. The hard,
solid feel which a part always possesses during the early stage of formation of an abscess,
is occasioned by the multiplication or proliferation of the nuclei, whilst the soA, fluctuating
later stage is due to the separation from each other of these nuclei, now changed into pus'
cells, by a fluid intercellular substance. Again, when pus fonns in the epidermis, or on the
surface of a mucous or serous membrane, it may be produced either from the sub-epithelial
connective tissue cells, or it may arise in an endogenous manner in the epithelial cells them-
selves. In the latter case the epithelial cells burst, and the pus-corpuscles, formed in the
interior, are set free.
The observations on which the statements made in this note are founded are recorded by
J. Goodsir (Anat. and Path. Observations, 1845), Virchow (Cellular Pathologic, 1858), Bill-
roth (Beitrage zur Path. Hist., 1858), in the later volumes of Virchow 's Archiv — by Buhl,
Bottcher, Forster, C. 0. Weber, Rindfleisch, Burckhardt, Sczelkow, Hjelt,and Cohnheim, and
by Haldane, in Edin. Med. Journal, November, 1862, by whom investigations have been made
on suppuration in bone, cartilage, the fibrous, muscular, and nervous tissues, skin, mucous and
serous membranes.
The Editor has. also, from a series of observations made on an inflamed pleura, observed
appearances which satisfied him that proliferation of the nuclei of the connective tissue-cor-
puscles of the serous membrane was taking place. His examination was conducted on sec-
tions made through the inflamed membrane at right angles to the surface. The inflammatory
lymph on the free surface of the pleura was soft, yellowish, and evidently but recently pro-
duced. It was composed almost entirely of cells, the structureless or dimly granular in-
ABSCESS. 267
From these and the like facts we have an almost exact parallel, in
their relations to pus, between the material for repair by granulations
and that exuded in the inflammatory process ; and between, if they
may be so called, the reparative and the inflammatory suppurations.
And in some of the facts we may trace a transition from the one process
to the other. In the formation of an acute abscess, for example, in-
flammatory lymph is transformed into pus ; then the pus, say, is
discharged; the signs of inflammation cease; the process of repar is
established, and reparative granulations line the abscess-cavity in the
place of, or formed by, the peripheral layer of the lymph. Now, pus
continues to be formed : but this pus is derived, not from inflammatory
lymph, but from granulation-substance. So, also, when an inflamed
part is cut, the first pus is from lymph : the latter pus, when repair is
in progress, is from granulation-substance. In both cases, alike, the
pus manifests itself as a rudimental substance ill-developed or dege
nerated (see p. 171) ; and the transition from the one condition to the
other is an evidence of the impossibility of exactly defining between the
inflammatory and the reparative processes, unless we can see their de-
sign and end.
Much, therefore, of what was said respecting suppuration in connec-
tion with repair, might be repeated here. But, avoiding this, let me
only point out the principal methods in which inflammatory suppuration
ensues, and the relation of the pus in each to the previous or coincident
inflammatory product. In this last respect, the suppuration of disease
differs in an important manner from that of the reparative process, in
that the degeneration may take place in any of the different varieties of
lymph, and that, according to the primary character of the lymph, there
may be traced (though as yet too obscurely) different appearances of
the pus."^
The methods of such suppuration may be named the circumscribed,
the diffuse, and the superficial. The first may be exemplified by the
formation of an abscess or a pustule ; the second by phlegmonous ery-
sipelas, or purulent infiltration of any organ ; the third by purulent
ophthalmia, or gonorrhoea : and in these and the like instances we may
tncellular substance being at a minimum. The proper epithelial covering of the pleura had
•ItGgether disappeared. The corpuscles of the subjacent connective tissue were evidently
i&Dcb changed from their normal state. They were swollen, and presented, in their interior^
■due two, others a larger number, occasionally half a dozen, of distinct, pale, faintly granular,
Qrcnlaror oval bodies, closely corresponding, in form and general aspect, to the corpuscles
of the inflammatory lymph. These were, without doubt, derived by division from the
original nuclei of the connective tissue cells. In different parts of the tissue might be traced
the gradations of this process : from cells, where the multiplication was evidently only com-
mencing, to others, where it had advanced to such an extent that crowds of the new-formed
Mroctarea existed, so as to obscure more or less completely the proper characters of the texture.
Additkmal observations made on an inflamed mucous membrane, in a case of inflammation
of the pelvis of the kidney and ureter, have also afforded results of a closely corresponding
natnre.
* See espeeially Rokitansky : Pathol. Anat. B. i, p. 210.
268 ABSCESS.
often, at the close of the disease, watch the transition from the suppura-
tion that depends on the inflammatory process, to that which is coin-
cident with repair.
In circumscribed suppuration, which has its most usual seat in the
areolar tissue, we can generally observe the previous signs of inflam-
mation, and of exudation of lymph in a certain area of the tissue. The
exudation is interstitial, or by infiltration ; and, probably, in most
acute abscesses, is of a mixed kind, containing both fibrine, which may
solidify, and a liquid material. The proper elements of the tissue are
separated or expanded by the lymph thus inserted among them ; and
the inflamed part derives from it much of its swelling, and much of its
hardness, while the fibrinous part of the lymph is solid. Generally,
such a swelling is at first, comparatively, ill-defined ; and if it be near
the skin, the visible inflammatory redness very gradually fades out at
its borders, where, in the deeper tissue, we may believe, the exudation
is gradually less abundant. But, in time, the swelling usually becomes
more defined ; the inflammation, as it were, concentrates itself, and ap:
pears more completely circumscribed. Now the lymph, in such a case,
may be absorbed, or may be developed so as to form a long-continuing
thickening and induration of the part : but, in the case I am supposing,
it is transformed into pus ; its corpuscles changing their characters in
the manner already described, and a portion, perhaps, of its previously
solidified part becoming liquid. The change almost always begins at or
near the centre of the lymph, where, we may believe, the conditions of
nutrition are most impaired. It may extend from a single point, or
from many which subsequently coalesce. In either case the central
collection of matter remains surrounded by a border or wall- of indurated
tissue, in which the infiltrated lymph is not transformed into pus, but,
rather, tends to be more highly organized. This border or peripheral
layer of lymph now forms the wall, as it is called, of the abscess, and
the finger may detect, as the best sign of abscess, a soft or fluctuating
swelling with a firm or hard border. The expressions commonly used
are, that the suppurative inflammation has taken place in the centre of
the swelling, and that its efiects are bounded by the adhesive inflamma-
tion : it might be said, with the same meaning, but perhaps more clearly,
that, of a certain quantity of lymph produced in the original area of
the inflammation, the central portions have degenerated into pus, and
the peripheral have been maintained or more highly developed : and
probably, we may add in explanation, the difierence has depended on
the degrees in which the conditions of nutrition have been interfered
with in the places in which the two portions have been seated. In the
central parts of an inflammatory swelling, the circulation, if not wholly
arrested, must be less free than in the peripheral ; the blood, moving
very slowly or stagnant, must lose more of its fitness for nutrition ; the
tissues themselves are more remote from the means of maintenance by
imbibition : in these parts, therefore, degeneration, if not death, ensues ;
while, iD the peripheral parts, maintenance, or even development, ia in
progress.*
Now, in the ordinary course of such an abscess, the purulent matter
is discharged. (I shall speak in the nest lecture of the manner in
which this takes place, as well as of the changes that ensue in the tis-
sues among whose elements the lymph is infiltrated.) On the iDterior
of its wall, especially if its course have been very acute, we may find a
thin, opaque, yellowish- white layer, easily to be detached, flaky, or
gmmons. It is usually formed of lymph-cells or pus-cells imbedded in
flakes of soft fibrinous substance. It has been made to seem more im-
portant than it is, by being called by some a " pyogenic membrane,"
and by its being supposed that it is the work of the cells to secrete the
pos. But the existence of such a layer is far from constant in abscesses ;
it is, often, a>sign of the imperfect orgaQization of the abscess-wall ; its
materials are probably oftener detached and mingled with the pus than
they are vascularized ; and no such layer is found when free suppuration
continues in an open abscess. A more normal course is observed when
the progress of suppuration has been slower. In this case, the wall of
the abscess becomes more highly organized after the discharge of the
contents; the circulation being restored in the infiltrated tissues of
which the wall is formed, the lymph is developed, or at least, if I may
BO speak, more highly vivified, and its cells, or new ones formed next
to the abscess-cavity, are constructed into granulations, and are sup-
Fig. 88.
pHed with bloodvessels, like those on the surface of a healing suppura-
■ing wound. Such vessels are represented in the sketch. (Fig. 38.)
With, or soon after, 'the evacuation of the purulent matter, the dis-
* £xpre*ninia me aomelimee used which imply ihni the wall orihe abaceu i« formed by
■itdbniva inSaimnalion fiilJowing, and purpose); consequeni on, i lie sup puraiive. This
nraialf happens, if ever, very rarely -. il only seeniB lo lake place when Buppuralion is ac-
WDpaoisd by eitendiDg in flam mat ion. Ia luch a case, thai which is to-dny the inilurated
>bKaw-wa]l, may, to-morrow, have become pus; and new inSammaiory products, formed
■nniid it dariog in degeneration, will foim iben, the boundary of ihe enlarged abscess, ll
Bay be, indeed, that the lymph situated al the centre of the inflammatory process is, nato-
nlly, !••■ DfBUiunble than that at the periphery; but ihis is not proved.
270 DIFFUSB BUPPDRXTIOIT.
oust' on mhich the absccHs depended may cease : and, if this be to, list
later progress of the case ia a process of healing which may, in tTtrj
essential character, be likened to the healing of a wound by gnnaW
tion. There ia the same gradual development of the lymph-cells, or, »
they might now be culled, the granulation-cells of the walls of the ib-
seees, — first of the deeper, and then of the more superficial cells. Tlw
same contraction, also, attends this process, and serves to diminnh tbe
area of the cavity, and to bring its walls more nearly into correBpon-
dence and proximity with the external opening, till, coming intu con-
tact, the opposite surfaces of granulations may unite, as in healing
hy secondary adhesion ; or till, as the edges of the opening arc retr»cl*d
and depressed, and the floor of the Abscess is raised, they are broa^t
nearly to a level, and heal as a single granulating sarfacc.
Such an abscess as I have described is often called acute or phlfg-
monous, in contradistinction from those collections of pus which, heirt;
formed without the observed signs of inflammation, and generallj
slowly, are named cold or chronic abscesses. Observations are wanting,
I believe, which might show how far the chronic abscesses differ from
such as I have described in their early condition ; and, espcciallj,
whether there be first a circumscribed infiltration of lymph, of whicH
part degenerates and the rest is developed. It is probable the phe-
nomena are essentially the same; for instances of all possible grid*-
tions between the two forms may be observed ; and, in the eomplctt
state of the chronic abscess, the structures are not widely different froa
those of the acute. The abscess-wall is usually firmer, more dcfin«J,
so that it can often be diiiseuled entire from ihe adjacent parts, and W
its tissue more developed, and more like those of a membranous cy";
the lining is generally less vascular, smoother, and less distinctly grann-
lated ; the contents are usually thin and serous, and indicate not odI;
that the material of which they are composed was peculiarly unapt v
he organized, but that, even after its transformation into pus, forlhet
degenerations ensued in it.
The dijfusc suppuration, as I have said, may be exemplified by piltj-
monous erysipelas. Here, with well-marked phenomena of inflamm*'
tion, lymph is exuded through a wide extent of the subcutaneous trtolu
tissue, and, from first to last, the boundaries of the exudation are it''
defined : the suppuration b, indeed, most certain and complete at ^
centre, or where the inflammation began ; but it may be nearly ««**'
tensive with the exudation, and most rarely presents a well-defiw'
boundary -wall, as in abscess. The lymph, in its primary character. »
mixeil ; its fibrinous constituent is evident in the coagulation ibattn-
sues when it is let out (see p. 230), and, usually, in the abundant nwlw"'
lar matter in the pus. The exudation is even more distinctly inUntil'*'
than in an abscess ; the tissue is thoroughly infiltrated with it, and >*<
SUPERFICIAL SUPPURATION. 271
comparatiyely, little expanded : and when suppuration has ensued, and
we cut into the inflamed parts, the pus often flows out slowly, even re-
mains entangled in the tissue. The same condition is, often, yet more
plain in the purulent infiltrations of such organs as the lungs ; their tis-
sues are completely soaked with pus. The infiltrated tissues themselves
are usually softened, not only by the mixture of the unorganized in-
flammatory matter, but through their own degeneration : and, very
generally, large portions of them perish, and are found as sloughs in-
filtrated with pus.
In regard to their structural changes, there may appear little diflfer-
ence between this condition and that of acute abscess, except in the
contrast of the one being less, the other more circumscribed. But in
regard to the materials exuded, they are, probably, in the phlegmonous
erysipelas, much less naturally apt for organization than in the abscess.
The central suppuration of an abscess, while the lymph around is or-
ganizing, implies that the degeneration depends much on the local de-
fect of the conditions of nutrition : the diflfuse suppuration seems due,
in a larger measure, to original defect of the lymph ; and these diflfer-
ences correspond with those of the constitutional states attending the
two diseases.
After the discharge of the pus, the healing of the diffuse suppuration
ia, in all essential respects, similar to that of the abscess; but the
methods of discharge are much more diverse. Sometimes, after exten-
sive sloughing of the skin, wide-spread suppurating cavities are exposed,
which then granulate and heal like wide-open wounds ; sometimes nu-
merous isolated suppurations ensue, whence the pus is discharged as from
so many small ill-defined abscesses, in each of which the ordinary heal-
ing occurs, while the intermediate parts are indurated by the imperfect
Organization of the lymph ; sometimes, from a comparatively small
opening, large sloughs are discharged, and then the boundaries of the
Subcutaneous cavities which they leave granulate, and healing takes
place as by secondary adhesion.
The superficial inflammatory suppuration is such as we observe in
gonorrhoea, and in purulent ophthalmia, and generally in the inflamma-
tions of mucous membranes. Here, the material exuded is least apt for
organization, partly because of the situation in which it is produced,
and partly through its own natural condition ; for though exudation
takes place, in these cases, within the tissue of the inflamed membrane,
as well as on its surface, yet the amount of thickening, or other struc-
tural change, that takes place is slight, if we compare it with the changes
that, in the same duration and severity of inflammation, would ensue
in connective tissue, or in serous membranes.
I have already spoken of the changes of mucus in the inflammatory
process, and of the mixture of lymph that then occurs. The lymph is
mostly of the corpuscular kind. It is, indeed, chiefly, in some of these
272 INFLAMMATORY SUPPURATION.
cases of inflamed mucous membranes, that one may doubt whether it is
reasonable to speak of the formation of lymph-cells as preceding that
of pus ; for, especially in the more acute inflammations, the characters
of pus-cells seem to be acquired in the very beginning of organization
of the exuded liquid. And this character of the cells is often retained,
even after the product of the inflamed membrane has regained, to the
naked eye, a more mucous appearance ; for here (unless ulceration of
the membrane have ensued) the process of recovery from inflammatory
suppuration is not through such healing by granulation, as in the former
cases, but by a gradual return to the secretion of a more normal mate-
rial ; and in this recovery, the inflammatory exudation becoming gra-
dually less, the corpuscles that are formed, though they may assume
the characters of pus-cells, are not sufficient to give a purulent character
to the liquid.*
The superficial suppuration from inflamed mucous membranes is
closely related to that from an ulcerated surface. I think, indeed, that
an inflamed mucous membrane may yield purulent matter, even though
it remain covered with an epithelium. I believe this happens in gonor-
rhoea, and in purulent ophthalmia ; the vascular tissues in these affec-
tions appear still to have epithelium on them, though perhaps it is too
thin and immature, and is reduced to a condition analogous to that of
the thin and moist glistening epidermis on the inflamed "weeping" leg.
But observations are wanting on this point. The transition to the sup-
puration from an ulcerated surface takes place when the epithelium is
wholly removed from a mucous membrane. This constitutes its abrasion
or excoriation ; in the next stage the surface of the membrane itself is
cast off", and this is its ulceration or erosion. f
Such are the several chief methods of inflammatory suppuration, and
the relations of the pus to other products of the disease. In all the cases
a point of contrast between pus and any form of lymph is to be found
in its complete incapacity for organization.
* The question of the diagnosis between mucus and pus should, perhaps, be here re-
ferred to. Between normal mucus and pus there can be no confusion. Between the ftiucus
and the pus of an inflamed mucous membrane, the difference corresponds, in some measure,
with that between lymph and pus; depending, first, on the proportion in which ihe in-
flammatory material is mingled with the proper constituents of the mucus, and, secondly,
on the degree in which the former tends t6 assume the purulent characters. In other words,
the diagnosis required is not, strictly speaking, so much between mucus and pus, as between
the lymph and pus which are, in different cases, mingled with the mucus of inflamed mem-
branes. And this diagnosis is one which it is easy to make, in many cases, according to
such characters of the corpuscles as have been already described j but, in other cases, it is
mpossible, if it so chance that the materials are in the transition-stage from lymph to pus.
t The thickness, or number of layers, of epithelium normally present on a mucous sur-
face would appear to exercise an important influence in determining whether suppuration
or ulceration should take place. On the urinary mucous membrane, for example, where the
epithelial layers are several, suppuration is the rule; whilst on the intestinal mucous mem-
brane, where the epithelial layer is single, ulceration most commonly occurs.
INFLAMMATORY SUPPURATION. 273
When once formed, the pus-cells, if they are retained within the body,
have no course but to degenerate further ; it is characteristic of their
being already degenerate, that they can neither increase nor develop
themselves. Various corpuscles found in pus, besides those I have
already mentioned^ may find their interpretation in these degenerations ;
for the pus-cells are prone to all the degenerations that I described as
occurring in the lymph-cells.
They may wither, as in the scabbing of pustular eruptions, ot in long-
retained and half-dried strumous abscesses.
Or, they may be broken up, whether before or after passing into the
fatty degeneration, which is one of their most common changes, and in
which they are transformed into granule-cells. It is this breaking
up into minute particles which, probably, precedes the final absorption
of pus.
Or, lastly, both the cells and the fluid part of the pus may alike yield
fatty and calcareous matter, and this may either remain difi^used in fluid,
or igay dry into a firm mortar-like substance.
It is to such degenerations as these, in various degrees and combina-
tions, and variously modified by circumstances, that we must ascribe
the diverse appearances of the contents of chronic abscesses, and of the
substances that remain when abscesses close without complete final dis-
charge of their contents. In such abscesses we may find mixtures of
pus-cells, granule-cells, and molecular matter, diS'used in more or less
liquid : or pus-cells, half-dried, shrivelled, and showing traces of their
divided nuclei ; or, all the cells may be broken up and their debris may
be found mingled with minute oily particles, which appear in such cases
to be always increasing ; or, with these may be abundant crystals of
cholesterine ; or, such crystals may predominate over all other solid
contents. In yet other chronic abscesses (though, still, without our
being able to tell why the pus should degenerate in these rather than in
the foregoing methods), we find molecules of carbonate and phosphate
of lime, mixed with fat molecules and crystals, which are diffused in an
opaque white fluid, and look like a deposit from lime-water, or like white
' oil-paint ; and as these contents dry in the healing of the abscess, so
^e formed the mortar-like deposits and the hard concretions such as
^ found in the substance of lymphatic glands, in the kidney, or other
organs that have been the seats of chronic abscesses.
Time and patience would fail in an attempt to describe all the varie-
ties of material that may thus issue from the transformation of pus.
What I have enumerated are the principal or typical forms with which,
I believe, nearly all others may be classed ; though not without consi-
deration of the various substances that may be accidentally mixed with
the pus ; as blood, debris of tissues, &c.
In conclusion of this part of the subject, — of this biography of inflam-
matory lymph, — a few words must be added respecting the degenera-
4 DEGBNERATIONS AND DISBASisd
ons and diseases which may occur after it is completely organized.
uhe degenerations to which I have now so often referred, may be ob-
lerved in fully formed adhesions, or in the corresponding organized
tissues in the substance of organs.
Of the wasting of adhesions we often see instances in the pericardium,
where films of false membrane are attached to one layer of the mem-
brane, while the opposed portion of the other layer is only thickened
and opaque. A more remarkable instance is presented in a case by
Bichat, in which a man made twelve or fifteen attempts at suicide, at
distant periods, by stabbing his abdomen. In the situations of the more
recent wounds, the intestines adhered to the walls of the abdomen ; in
those of the older wounds, the older adhesions were reduced to narrow
bands, or were divided and hung in shreds.
To similar wasting atrophy we may refer the extreme thinning and
perforation of false membranes, by which, as Virchow* has weU de-
scribed, they become fenestrated like wasted omentum.
Of fatty degeneration I have seen no good examples in adhesions or
similar inflammatory products, but of calcareous degenerations, or of
such as present a combination of fatty and earthy matter, museums pre-
sent abundant specimens. Among these are most of the plates of bone-
like substances imbedded in adhesions of the pleura, in thickened and
opaque portions of the cardiac pericardium, in the tunica vaginalis, in
old hydroceles, in the thickened and nodulated capsule of the spleen, in
the similarly altered mitral and aortic valves. So, too, many of the so-
called ossifications of muscles and ligaments are examples of calcareous
degeneration of fibrous tissue, formed in consequence of inflammation
of these parts, and imbedded in masses of fibrous-looking bands, within
their substance. In some of these cases, indeed, there may be am.
approximation to the characters of true bone (p. 85) ; but in others tho
earthy matter is deposited in an amorphous form, and seems to take the
place of the former substance, as if, according to Rokitansky, it were a
residue of the transformation of the more organized tissue, whose soluble
parts have been, after decomposition, absorbed.f
Pigmental degeneration of adhesions may be seen, sometimes, in
those of the pleura, in which black spots appear like the pigment-
marks of the lungs and bronchial glands. J Adhesions of the iris, also,
may become quite black, by the formation of pigment like that of the
uvea.
Lastly, it must be counted among the signs of its attainment of com-
plete membership in the economy, that the organized product of inflam-
mation is liable to the same diseases as the parts among which it is
placed ; that it reacts like them under irritation ; is, like them, aflFected
* WOrzburg Verhandlungen, B. i, p. 141.
f Numerous specimens of the calcareous degeneration of adhesions are in the Collegf
Museum; e.y. Nos. 103, 1493, 1494, 1516, &c.
f As in No. 96 in the College Museum.
OF ORGANIZED LYMPH. 275
by morbid materials conveyed to it in the blood ; and, like them, may
be the seat of growth of new and morbid organisms. No more complete
proof of correspondence with the rest of the body could be afiForded
than this fact presents ; for it shows that a morbid material in the
blood, minute as is the test which it applies, finds in the product of in-
flammation the same qualities as in the older tissue to which it has
peculiar affinity.
The subject, however, of the diseases to which these substances,
themselves the products of disease, are liable, has been little studied.
I can only enumerate the chief of them.
Lymph, while it is being highly organized, is often the seat of
hemorrhage; its delicate new-formed vessels bursting, under some ex-
ternal violence, or some increased interior pressure, and shedding blood.
Such are most of the instances of hemorrhagic pericarditis, and other
hemorrhages into inflamed serous sacs.
Even more frequently, the lymph, when organized, becomes itself
the seat of fresh inflammation. Thus, in the serous membranes, we
may find adhesions, in the substance or interstices of which recent
lymph or pus is deposited ;* or, in other cases, adhesions, or the
diickenings and opacities of parts, become highly vascular and swollen.
It is, indeed, very probable that, in many of the instances of the recur-
ring inflammations that we watch in joints, or bones, or other parts, the
seat of the disease is, after the first attack, as much in the organized
product of the former disease as in the original tissue.
I suppose, also, that to such inflammations of organized inflammatory
products, we may ascribe many of the occasional aggravations of
chronic inflammations in organs ; the renewed pains and swellings of
anchylosed joints, of syphilitic nodes, and the like ; which are so apt
to occur on exposure to cold or in any otherwise trivial disturbances of
the economy. In such cases we may believe that the former seat of
disease becomes more inflamed, and that with it are involved the or-
ganized products of its previous inflammations. And in such cases
there are, perhaps, none of the effects of inflammation which may not
ensue in the newly organized parts : evidently, they may be softened.
Of thickened and indurated, and made more firmly adherent : or they
tHay be involved in ulceration, or may slough with the older tissues
^mong which they are placed.
Lastly, the products of inflammation may be the seats of the morbid
deposits of specific diseases. In their rudimental state they may in-
Corporate the specific virus of inoculable diseases; such as primary
Syphilis, variola, and the rest, and, when fully organized, they may be
the seat of cancer and tubercle.
* As in No. 1512 in the College Museum. The specimen has some historic interest. It
is one of those by which, in 1808, attention was first drawn, by Sir David Dundas, to the
cooDectioa between acute rheumatism and disease of the heart.
276 SOFTENING OF INFLAMED PARTS.
LECTURE XVII.
CHANGES PRODUCED BY INFLAMMATION IN THE TISSUES OF THE
AFFECTED PART.
The account of the results of inflammation in the tissues of the part
in which it has its seat, will include the chief among those destruc-
tive processes which, I said in a former lecture (p. 229), may be reckoned
as a second division in the inflammatory changes of the nutritive pro-
cess. For I believe that all the effects of inflammation are injurious, if
not destructive, to the proper tissues of the part in which it is seated.
All the changes I shall have to describe are characteristic of defect of
the normal nutrition in the parts : they are examples either of local
death, or of some of the varieties of degeneration, modified and pecu-
liarly accelerated by the circumstances in which they occur. The dege-
nerations are observed most evidently, in the processes of softening and
absorption of inflamed parts. These I shall, first, endeavor to illus-
trate ; and then, after some account of the minute changes that are
associated with them, I will describe the process of ulceration : reserving
for another lecture the account of the death of parts that may occur in
inflammation.
Let me, however, at once state that the changes in the proper tissues
of an inflamed part are, generally, of twofold origin. (1.) They are
due to the natural degeneration of the tissue. That degeneration,
which would be progressive in the healthy state, but which would then
be unobserved, being constantly repaired, is still progressive in the in-
flamed state of the part, and is the more rapid because of the suspen-
sion or impairment of the proper conditions of nutrition. (2.) They are
due, also, to the penetration of the products of inflammation into the
very substance of the affected tissue ; not merely into the interstices of
its elemental structures, but into those structures themselves. These
two methods of change are not essentially connected ; but they are
generally, in various proportions, coincident and mutually influential ;
and when concurring it is hardly possible to assign to each its share in
the result to which they lead.
One of the most common effects of inflammation in an organ is a more
or less speedy softening of its substance ; and this is due not only to
infiltration of it with fluid, but to a proper loss of consistency, a change
approaching to liquefaction, or to disintegration, of which, indeed, it is
often the first stage. Of such softening, some of the best examples are
in the true inflammatory softening of the brain and spinal cord, in
which the softened part is usually found to consist of broken up nervous
substance, together with more or less abundant granular products of
inflammation. Such softening also may be found in the lungs : the pe-
culiar brittleness and rottenness of texture, which exist with the other
SOFTENING OF INFLAMED PARTS.
277
characters of hepatization^ are evidently due to changes in the proper
tissue, more than to incorporation of the products of inflammation. In
staphyloma of the cornea, similar softening ensues in connection with
the opacity and other changes of appearance. But, perhaps, the most
striking instance of softening in inflammation (and it is the more so be-
cause the softening probably precedes the other evident signs of inflam-
mation'^) is to be found in bones. One may generally notice that an
acutely inflamed bone is soft, so that a knife will easily penetrate it.
Thus it may be found in the phalanges of the fingers when^ they par-
take in deep-seated inflammation, and thus, sometimes, in the neighbor-
hood of diseased joints. The change depends partly on an absorption
of the earthy matter of the bone, this constituent being removed more
quickly, and in greater proportion, than the animal matter ; but the
entire material of the bone is softened, f
The softening of bones may permit peculiar subsequent changes,
especially their swelling and expansion. Thus, in a remarkable case
communicated by Mr. Arnott to Mr. Stanley, after excision of the
bones of an elbow joint, inflamma-
tion ensued in the shaft of the hume-
rus, and after four months the pa-
tient died. The end of the humerus
was full-red, and swollen, with ex-
pansion or separation of the layers
©fits walls (Fig. 39). And the case
showed well the coincidence of ab-
sorption and of enlargement by ex-
pansion ; for though the inflamed
humerus was thus enlarged, and con-
tained more blood than the healthy
one, " yet it was found not to weigh
80 much by half.''
Similar expansions of bone, with
&I1 the characters of inflammation,
^nd such as could not have hap-
pened without previous softening
of the tissues, form part of the
i&any swollen and enlarged bones
Fig. 39.t
* See Kftss, as quoted by Virchow, in his Archiv, i, p. 121.
t In inflammation and caries of bone, in addition to the soflening caused by the removal
^iTthe earthy matter there is also a considerable widening of the Haversian canals, lacuntp,
>Qd canaliculi, so that many of them disappear, owing to numerous spaces and canals being
ibrowD together. See, for a more detailed description of the process, Goodsir, Anat. and
hih. Oba., v. Bibra, Liebig and Wohler's Annalen. vol. 55; Harwell, Diseases of Joints.
X Fig. 39. A, the inflamed humerus. The swelling of its lower part is shown by con-
tiast with that of the corresponding part of the healthy humerus, B. The separation of
bminse is shown in 0 ; all the figures are reduced one-half. From Mr. Stanley's Illustra-
tioni» PI. i, Figs. 4, 5, 6.
BOFTENING OF INFLAMED PARTS.
which are comtnon in all museums.* Doubtless, Id many of these cases,
the disease has been of very slow progress, aod the separation of the
several layers of the compact bone, which the speciiiieus display, must
be ascribed to their gradually altered form, as lliey have grown about
the enlarging bloodvessels and interlaminar inflammatory materials.
But, in other cases the expansion has in all probability been more rapid,
the softened bone yielding and extending, as the naturally softer tissues
do, in an inflammatory swelling.
Th^characters of a bone thus expanded are easily discerned. Ita
substance may be irregularly cancellous or porous; but the most strik-
ing change is a more or less extensive and wide separation of the con-
centric laminfe of the walls of the bone, so that, as in the section of
this femur (Fig. 40), the longitudinal section of the enlarged wall appears
composed of two or more layers of compact tissue, with a widely can-
cellous tissue between them : and these layers may sometimes be traced
into continuity with those forming the healthy portion of the wall.
Usually, the separated layers are carried outwards, and the bone ap-
pears outwardly enlarged ; but aometimt-s the inner layers of the wall
are pressed inwards and encroach upon the medullary tissue. In the
first periods of the disease, the cancellous tis-
sue between the separated layers of the wall -
has wide spaces, which are usually filled with i
blood-colored medulla : but this tissue, like the I
often coincident external formations of new '
hone, appears to have a tendency to become i
solid and bard ; and its fibrils and laminse may |
thicken till they coalesce into a compact ivory-
like substance, harder than the healthy hone.
Again, for examples of softening in inflam-
mation, I may adduce the softening of ljg»-
ments, such as permits that great yielding of
them which we almost always see in cases of
inflamed joints. This is not from mere defec-
tive nutrition; for it does not happen in (he
same form, or time, or measure, in cases of pa-
ralysis or paraplegia engendering eitreoe
emaciation. Neither ia it from the soaking of
the ligaments with the fluid products of lli«
inflammation; for it does not happen in l!w
abundant cfi'usions of the slighter inflammniions
of the joints ; and when ligaments are long ma-
cerated in water they yet retain nearly all liioir
inextensibility. It appears to be a peculiar
softening, or diminished cohesion of the proper
• In Itie College Muwiim, Nos. 503 to SOO, and 3DS5 lo 30Bi ; Biid in Ibe MuMun of
Sl BBtLliolomew's, Serlpt i, New. f>G, «.], 13S, 106, lOT, 19B, &c.
f Fig. 40, Fmni ■ ipeoimeii in Uia Miuaum al Sl Barlholi>mi)w'% SenM i, Ha, H-
INTEB8TITIAL ABSORPTION OF INFLAMBD PARTS. 279
tissue of the ligaments ; the result of a degeneration combined with in-
filtration of inflammatory products.
We may see such changes in the ligaments of all joints ; in the hip,
in the cases of spontaneous dislocation occasionally seen, independent
of suppuration or ulceration of the parts belonging to the joint ; in the
wrist, when the ulna after disease, becomes so prominent ; in the verte-
bra, especially in the ligaments of the atlas and axis. But we see the
effects of this softening best in diseased knee-joints and elbow-joints ;
and in all these cases we may often observe an interesting later change
when the inflammation passes by. The ligaments, softened during the
inflammation, yield to the weight of the limb, or more rarely, to a mus-
cular force, and the joint is distorted. Then, if the inflammation sub-
sides, and the normal method of nutrition in the joint is restored, the
elongated ligaments recover their toughness, or are even indurated by
the organization or contraction of the inflammatory products within
them. But they do not recover their due position ; and thus the joint
is stiffened in the distortion to which its ligaments had yielded in the
former period of inflammation. In the crowds of stiff, distorted, and
yet not immovably fixed, joints, that one sees as the consequences of
inflammation, these changes must generally have happened to the liga-
ments : first softening and yielding ; then recovery, with induration,
and perhaps some contraction, due to their atrophy and the organiza-
tion of the inflammatory material. The cases are aggravated by similar
changes in the adjacent parts ; for the stiffness of such joints is not due
to the ligaments alone ; all the subcutaneous tissues are apt to be adhe-
rent and indurated.
The absorption of the affected tissues is another example of the
destructive changes ensuing in the inflammatory process. Like the
degenerations, which, probably, always precede it, it is, in many in-
flammatory conditions, a peculiarly rapid event ; and it may affect, at
once, the proper elements of a part, its bloodvessels, and the inflamma-
tory products that may have been previously formed among them.
I shall refer here only to that which has been called interstitial ab-
sorption; to the removal of parts from within the very substance of the
tissues, as distinguished from the removal by the ejection of particles
from the surface, of which I shall afterwards speak as occurring in
vleeration.
Interstitial absorption of inflamed parts is seen very well in inflamed
bones. The head of a bone may be scarcely enlarged, while its interior
is hollowed out by an abscess ; what remains of the bone may be in-
durated, as by slight and tardy inflammation, but so much of the bone
as was where now the abscess is, must have been inflamed and absorbed.
The changes are well shown in the instance of abscess in the lower end
of the tibia which is here drawn (Fig. 41).* Here, too, the evidence of
* Museum of St. Bartholomew^ Ser. i, No. 82.
INTERSTITIAL .
SORPTION OF INFLAM
absorption Is completed by the similar excavations formed in bonea
within which cysts and tumors grow ; for in these caacs no other removal
than by absorption seems possible.
To similar absorption of inflamed tissue we may refer the wasting
that we noticed in the heads of bones that have been the scat of chronic
rheumatism. The best examples of this are in the head and neck of
the femur ; and the retention of the compact layer of bone covering in
the wasted cancellous tissue of the shortened neck and flattened head,
is characteristic of interstitial absorption, as distinguished from ulcera-
tion, by which the cancellous tissue is commonly exposed. In these
cases of chronic inflammation of the hones, we may notice, also, an
appearance of degeneration that precedes a peculiar mode of absorption
Fig. 41.
Fig. 42.
or of ulceration. While the articular cartilages are passing througli
the stages of fibrous degeneration, and are being gradually removed.
the subjacent bone is assuming the peculiar hardness which has been
termed "eburnation," or " porcellaneous" change. Now, this change
is effected by the formation of very imperfect hone; of bone that hw
no well-formed corpuscles ; and it resembles the result of mere calcare-
ous degeneration rather than a genuine ossifying induration. And lU
character as a degeneration is further declared in this ; that it is prone
to destructive perforating ulceration, which often gives a peculJW
worm-eaten appearance to the bones thus disea^ied.*
• Hein (Virchow'» Archiv, B. xiii. p. IS, leiaS) aiates iliat the warm-eaKn aperlurM in
DOcupied in the recent iMIo with villoaB-like proceiMi of the d^enaimu fibrooaRiUgt. A
INTBRSTITIAL ABSORPTION OF INFLAMED PARTS. 281
With these changes in rheumatic bones we may also cite, as instances
of absorption daring slow inflammation, the ^changes which Mr. Gulli-
ver* first described as apt to ensue after injuries about the trochanter
of the femur (Fig. 42). In such cases, without any appearance of
ulcerative destruction, the head and neck of the femur may waste by
absorption, the neck becoming shortened and the head assuming a
peculiar conical form. We might regard these effects as simple atro-
phy, if it were not that they are like the effects of the more manifest
inflammation in the rheumatic cases, and that the existence of inflam-
mation during life is often declared by the abiding pain and other
symptoms following the injury.
Again, other examples of the absorption of inflamed parts, or of
parts that have }>een inflamed, are presented in the wasting of glands
after inflammation ; as in cirrhosis of the liver, in some forms of granu-
lar degenerations of the kidney, in the indurated and contracted lung
after pneumonia.
No doubt, in these cases, the reduction of the organ depends, in a
measure, on the contraction of the diS'used inflammatory product, as it
organizes ; but in many cases the quantity of new tissue is extremely
small (it is so in the shrivelled granular kidney) ; and, in all the cases,
we may well doubt whether the contraction of organizing lymph would
produce such extensive and uniform absorption of the proper substance
of an organ, if there were not a previous condition favoring the absorp-
tion. The most probable explanation of these cases seems to be, that
as, in the early periods of the inflammation, the softening and the
degeneration of the inflamed tissues coincide with the production of the
lymph ; so, as the inflammation subsides, and subsequently, the absorp-
tion of the degenerated tissues may often coincide with the full organi-
zation and contraction of the lymph. And it is altogether most proba-
ble that these events are independent though concurrent ; and that each
occurs as of itself, not as the cause or consequence of the others.
To all these cases must be added the fact of the absorption of the
bloodvessels, and other accessory apparatus, of the inflamed tissues.
The absorption of the absorbents themselves must coincide with that of
the tissues. What a problem is here ! These, that had once been the
apparatus maintaining life, that had been adjusted to its energy and
fashion, now, as it fails, remove themselves in adaptation to its failure.
How can this be ? We can only guess that its method is just the reverse
of the method of formation ; that, as in growth the bloodvessels and
chaise, which appears to correspond with the eburnation of bone, is described by Mr.
Tomes, as occurring in a part of a tooth which lies beneath a carious cavity. In both cases
the ipduratioo might suggest that it is calculated to retard the progress of the disease, but
we baTe no evidence that it does this in an effective manner ; and in the case of the
bones there is every appearance that the destruction is most rapid where there is most
induration.
* Edinburgh Med. and Surg. Journal, vol. 46. His illustration of a well-marked case is
here oc^ned. — ^The change is illustrated in No. 3312 in the College Museum.
19
Ijrmphatics follow in the course of evolution of the growing pftrti, opn>-
ing and extending into each new part as it forms, so, in decreaae, ihrj
fulliiw, ami closing in hannoniouely with the general involution, ni^le
their degenerate materials with those of the tissue, and are absorbed bjr
the nearest remaining streams of blood.
Once more ; not only the original elements of the lissuo bmj ii
absorbed, but, even more rapidly, the new-formed products uf inflomM-
tion. We have the best examples of this, as well »s, indeed, of nut
of the facts which I have been mentioning, in the spontaneous openinK
uf a common abscess; which though it be so common a thing, I will
venture to describe here.
Let us suppose the cose of an abscess formed in the subciitanrouf li»
sue : of such a one as I described some pages back, and may illusinif
by this sketch of an imaginary section through its cavity and the Iupt^
jacent skin (Fig. 43). It has had its origin in lymph infiUrated thn>ii|t
Fig, «,
I
a ccrliiin nrca of the tissues, anil forming therein a hard circmnseribe*
inflamod mass. Of this lymph all the central portion is 8sppiifitf>i
and forms the purulent contents of the abscess; while the p«HptHT*l
part acquires more abundant bloodvessels, assumes the cbartottrof •
granulation-layer on its surface, and forms the proper wall of thetb'
sccss.
The pus of such an abscess as this will contain, probably, beaidM '
proper constituents, some of the diaentegratetl tissue of the piit
which it has its seat. We cannot, indeed, be quite sure of this; for i*
may be, that while the lymph is being formed, or being converted iot"
pus, the proper tissue of the infiltrated part is undergoing absorptioo
and although, in the pus of abscesses thus formed, we often find «biO>'
ilant molecular and granular matter, yet this maybe the liftro, »<»'
of the tissue, but of the cells or fibrine of the inflammatory prodie*-
We cannot, I think, be sure on this matter ; but we may be snretlMt'
of these two events occurs ; that the circumscribed portion of IJM^j*
OPENING OF ABSCESSES. 283
which such an abscess has its seat, degenerates; and is then either
absorbed, or else disintegrated, so as to mingle more or less of its sub-
stance with the pus.
The abscess thus formed has a natural tendency to open, unless all
the inflammation in which it had its origin subsides. Inflammation
appears to be not only conducive, but essential, to the spontaneous
opening of abscesses ; for, where it is absent, the matter of chronic
abscesses will remain, like the contents of any cyst, quiet for weeks, or
months, or years ; and when in chronic abscesses, or in cysts, inflamma-
tion ensues through the whole thickness of their coverings, it is usually
certain that their opening is near at hand. This difference between
acute and chronic abscesses makes it very doubtful whether the in-
flammation of the coverings of an abscess can be ascribed to any local
influence of the pus. Bat to whatever it may be ascribed, we may
refer to this inflammation, and to the degenerative changes that accom-
pany it, the comparatively quick absorption of the integuments and of
the infiltrated lymph, over the collection of pus : and thus the fact,
however we may account for it, that the integuments are more prone
to inflammation and more actively engaged in it, than the other tissues
about an abscess are, may be used to explain the progress of matter
towards the surface. Possibly (though this, I think, is much less pro-
bable) the tissues and the lymph between an abscess and the surface
may, after the degeneration which accompanies the inflammation, be
disintegrated, and may mingle their molecules with the purulent con-
tents of the abscess. But, in favor of the belief that they are absorbed,
we have the evidence of analogy ; for just the same thinning and re-
moval of integuments takes place when they inflame over a chronic
abscess with a thick impenetrable cyst, or over an encysted or even a
solid tumor. In these cases, absorption alone is possible ; and the
cases are so similar to the ordinary progress of abscesses, that I think
we may assign all the changes of the integuments over these to the
same interstitial absorption.
During, or preparatory to their absorption, the integuments over an
abscess become softer and more yielding. The change is, most pro-
bably, due to such softening as I have described in degenerating in-
flamed parts. It takes place especially in the portion of the integu-
ments over the middle, or over the most dependent part, of the abscess ;
and this most softened portion, yielding most to the pressure of the
pus, becomes prominent beyond the parts around it, and points, Mr.
Hunter refers to this as " the relaxing or elongating process." He
says : " Besides these two modes of removing whole parts, acting singly
or together [that is, besides the interstitial and the progressive absorp-
tion], there is an operation totally distinct from either, and this is a
relaxing and elongating process carried on between the abscess and the
skin, and at those parts only where the matter begins to point. It is
poesible that this relaxing, elongating, or weakening process, may aH
284 ABSORPTION OF INFLAMED PARTS.
in some degree from the absorption of th^ interior parts ; but there is
certainly something more, for the skin that covers an abscess is always
looser than a part that gives way from mere mechanical distension, ex-
cepting the increase of the abscess is very rapid.
" That parts relax or elongate without mechanical force, but froiH
particular stimuli, is evident in the female parts of generation, before
the birth of the foetus ; they become relaxed prior to any pressure.
The old women in the country can tell when a hen is going to lay from
the parts becoming loose about the anus.*'*
While these changes of degeneration, leading to softening and ab-
sorption, are ensuing in the cutis and the lymph over such an abscess
as I have described, we commonly notice that the cuticle separates,
leaving the very point, or most prominent part, of the abscess bare
(Fig. 43). The cuticle is sometimes raised as in a blister ; but much
more often it cracks and separates, and then, with its broken edges
raised, peels off like dead cuticle : and we may believe that it is dead,
partaking of the failure of nutrition in which all the parts over the
abscess are involved, and being removed as a dead, not as a merely de-
generated, part.
At len^gth, after extreme thinning of the integuments, they perish in
the centre of the most prominent part. Sometimes the perished part
becomes dry and parchment-like, with a kind of dry gangrene ; bat
much more commonly a very small ordinary slough is formed, and the
detachment of this gives issue to the purulent matter. The discharge
is usually followed by a more or less complete cessation of the inflamma-
tion in the integuments, and then the wall of the abscess, having the
character of a cavity lined with healthy granulation, heals.
The softening and absorption of inflamed tissues of which I have
been speaking, are the chief consequences, or attendants, of minuter
molecular changes, to which I must now refer. These changes are de-
rived, as I have already said, from one or both of two sources ; namely,
the natural degenerations of the inflamed tissues, and their penetration
by the inflammatory product.
The rapid softening of an inflamed tissue is, probably, iu most cases,
dependent on both these conditions ; arid yet in some cases, and in
some measure in all, it may be ascribed to a simple degeneration, such
as might be classed with those named liquefactive. Thus, in the case
of the integuments over an abscess, we find it associated with infiltra-
tion of degenerating lymph-products, and probably in some measure
due to their presence : but in the brain and spinal cord, the softenings
of inflammation are, in structure, and probably also in nature, very like
those of mere atrophy.
* On the Blood, &c. Works, vol. iii, p. 477. The last fact is, probably, not appropri*
ately cited. The change in the state of parts before the birth is most likely due to relaxa-
tion of the abundant muscular fibres that they all contain.
DBOEKERATIONS OF INFLAMED TISSUES. 286
Less rapid softening is often connected with a well-marked fatty de-
generation of the inflamed tissues. This is especially the case in the
muscles, bones, cartilages, cornea, and certain glands, as the liver and
kidney.
I found such a degeneration well marked in the fibres of the heart of
a man, who thrust a needle through his left ventricle four days before
his death. There were evident signs of pericarditis, and of inflamma-
tion of the portion of the heart close by the wound; and both in this
portion, and, in a less degree, in all other parts of the heart, I found
such a fatty degeneration of the muscular fibres as I could not have
distinguished from that which occurs in the corresponding atrophous
degeneration. The same changes may be oftener observed at later
periods after inflammation of the substance of the heart ; and in some
of these cases the interstitial deposits of lymph are organized into
fibrous tissue, while the muscular fibres themselves are degenerate.
The extended observations of Virchow, on the inflammations of mus-
cles,* show that such fatty degeneration of the fibres usually occurs in
nearly all but the most acute cases ; in these, softening and disintegra-
tion of the muscular fibrils rapidly ensue, and fatty particles appear
subsequently, if at all, in the inflammatory exudation and disintegrated
tissue that are mingled with the sarcolemma. He shows, also, very
clearly, how the changes in the muscular fibres may be associated with
the eflfects of lymph produced interstitially among them, as well as
within them, and passing through its ordinary progress of development
or degeneration ; and that they may be followed by the complete wast-
ing, or absorption, of the degenerate tissue, in the place of which the
new fibrous tissue formed by the developed lymph may remain like a
scar or a tendinous spot.
In inflamed bone, also, Virchow has traced fatty degeneration as a
part of the process of softening which precedes its expansion or absorp-
tion. The change is observed not constantly, yet very often, as a fatty
degeneration of the bone-corpuscles, in the interior of which small fatty
molecules appear. After, or sometimes without, such previous changes
in the corpuscles, he has also traced their enlargement and the gradual
softening, disintegration, and final liquefaction and separation of the
proper bone-substance, immediately surrounding and including each cor-
puscle. The changes he has thus traced accord completely with those
described by Goodsirf and RedfernJ in the cartilage ; and as he well
observes, they have peculiar interest in relation to the occurrence of
degeneration, as a part of the inflammatory process, inasmuch as they
are the results of the same process as that by which, normally, the
medullary spaces and areolae of growing bone are formed, by which, as
* In his essay on Parenchymatous Inflnmmation, Archiv, B. iv, h. i, p. 266.
f Anatomical and Pathological Observations, 1845.
^ A normal Nutrition in Articular cartilages: Edinburgh, 1850. And "On the Healing
of Wounds in Articular Cartilages," in the Monthly Journal of Medical Science^ Sept., 1S51.
286 DBGENBRATIONS OF INFLAMED PARTS.
the bone grows, the compact cortical tissue is gradually changed into
areolar or spongy tissue, and by which the peculiar " mollities ossium/'
or "osteomalacia," is produced.
Changes like these in inflamed bone have been found in ulcerating
and articular cartilage ; and they are here the more important, as show-
ing the process essentially similar to the degeneration of inflammation,
although occurring in a tissue that has no bloodvessels, and into which
we have no evidence of the penetration of lymph. They have been
chiefly observed by Goodsir and Redfern ; but have been confirmed by
many.* They consist essentially in the enlargement of the cartilage-
cells, with increase of the nuclei, or of peculiar corpuscles contained in
them, or with fatty degeneration of their contents, and fading, or similar
degeneration of their nuclei. The hyaline intercellular substance at the
same time splits up, and softens into a gelatinous and finely molecular
and dotted substance, or else is gradually transformed, in the less acute
cases, into a more or less fibrous tissue. The enlarged cartilage-cells
on the surface are released, and may discharge their contents on the
surface of the ulcer ; and the intercellular substance is gradually dis-
integrated and similarly discharged, or, whatever part of it remains, is
transformed into fibrous tissue, and becomes the scar by which the
ulceration is, in a measure, healed.
Lastly, in the cornea, a series of observations on the eifects of in-
flammation, purposely excited in it by various stimuli,t have shown that
the changes in it are not due to any free exudation of lymph in it, but
to alteration in its proper constituent textures. They consist, chiefly,
in swelling and enlargement of its corpuscles, the appearance of minute
fatty molecules in them, and the increase and enlargement of their
nuclei. The intercellular substance becomes, at the same time, turbid,
more opaque, denser, more fibrous, and, sometimes, finely granulated ;
and in some cases, fatty molecules appear in it. The changes thus pro-
duced in the cornea are not essentially difi'erent from those that follow
its idiopathic inflammations ; and, as Virchow concludes, they are ex-
tremely like those of the arcus senilis.
Now, from all these cases, with which others of similar import might
be combined, we may conclude that the degeneration of the proper tis-
sues of inflamed parts, which we recognize in the mass as a softening
of their substance, or an aptness to be absorbed, is, very often, essen-
* Reference may be especially made to a paper by C. O. Weber, in Virchow's ArchiT,
B. xiii, 1858, and to Barwell's Treatise on Diseases of Joints, 18G1. The former author de>
scribes new vessels as extending, not only over the surface of the ulcerating cariila{ce^ but
afterwards penetrating its substance,
f They are published briefly in Virchow's essay already cited ; and in detail in a dis8C^
tation — " Der normale Ban (W.t Cornea und die pathologifcchen Abweichungen in demselben,"'
Wiirzburg, 1851 — by Fr. Strube, by whom the observations were made under the superin-
tendence of Virchow, Additional and more extended observations have been made by His
in the WUrzburg Verhandl. vol. iv, and in Virchow's Archiv, vol. vi, and by Rindfleiflch
in the Archiv, vol. xvii, 1859.
DEGENERATIONS OF INFLAMED PARTS. 287
tially like the fatty degeneration which we have studied as a form of
atrophy of the same parts ; that the changes of structure are, in both,
essentially the same ; diifering in rate of progress, but not in method or
result. And the cases of the bones, cartilages, and cornea, are the
more to be considered, because the changes described in them cannot
be referred, in any considerable measure, if at all, to a process of exu-
dation into the elements of their tissues.
The fatty degeneration and that of softening, as by progressive
liquefaction, are, doubtless, the most general forms in which the defec-
tive nutrition in an inflamed part is manifested. But something allied
to the calcareous degeneration occurs in the ossifications of the laryn-
geal cartilages when they are involved in inflammation, and of such
other cartilages as are prone to an imperfect ossification in old age.
These are frequent events ; and as Virchow observes, the ossification
occurs constantly and often exclusively in the very part of the carti-
lages which corresponds with the seat of the inflammation. To the same
class of cases we may refer the ossifications of parts of the articular
cartilages in chronic rheumatic arthritis and the formation of the im-
perfect dentine or osteo-dentine which ensues in inflammatory afiections
of the tooth-pulp, or in the pulp of the elephant's tusk around bullets
lodged in it. In all these cases it may be observed, the inflammatory
process is attended with such changes as occur almost normally at some
later period of life, or in old age ; such changes, then occurring, are
reckoned among the natural degenerations, the signs of simply defec-
tive formative power : the difierence, therefore, between the natural
degeneration and that of the inflammatory process seems to be one of
time more than of kind ; the inflammatory is premature and compara-
tively rapid, and ensues with the characters of disturbed, rather than of
merely defective, nutrition.
Such are some of the evidences of degeneration ensuing in the proper
tissues of inflamed parts. The cases I have selected are of the simplest
kind ; whose results are least confused by the changes that may ensue
in lymph penetrating the degenerating tissue. When this happens, it
is perhaps impossible, at present, to separate the two series of changes ;
those, I mean, which are due to the degeneration of the elements of the
tissue, and those which are occurring in the lymph within them. The
latter are especially described by Virchow in the muscular fibres, and
in the renal cells, in what he calls the parenchymatous form of granu-
lar degeneration of the kidney. In the latter he says* that while, as in
the croupous form, fibrinous cylinders of free inflammatory exudation
may be found in the straight, and a part of the convoluted tubes, other
changes are ensuing in the epithelial cells ; and by these chiefly, and
sometimes alone, the characteristic altered structure of the kidney is
•
* Id his esseyf referred to at p. 320. Many of his facts were published by one of his
papils, Dr. Neimann, in his dissertation, ^ De inflammatione renum parenchymatosai BeroU
1848."
inilnccd. They occur oapecially iu those parts of the tubes which raa
tranaversely or obliquely. In the 6rst stage of the disease these oeQi
enliirge, and their molecular nitrogenous contents increase, by the pent-
tratioQ of the inflammatory product into them. In the second Mtp^
the increase is such that the cells break up, and the urine-tubes appnr
filled with a molecular albuminous substance ; or else the fatty tranifur-
mation ensues in thoni, and they are filled with finely granular fitiji
matter, and Appear as granule-cells or granule-masses. In the third
stage the fat-granules dispart, and an emulsive fluid is formed, whidi
may be absorbed or discharged with the urine.
Virchow describes similar changes in the hepatic cells : but it mn
suffice only to refer to these. What has been already described will bi
enough, I hope, to justify the expressions used at the beginning of the
lecture: namely, that the changes (short of death) which ensue in the
proper elements of an inflamed part are twofold : first, those of ■ lir-
generation, such as might ensue in simply defective or suapend<-d nntri-
tion ; and. secondly, those which depend on the penetration of the exuded
inflammatory product. Either of these may, perhaps, occur alone, bn
the first can be rarely, if ever, absent. When they arc concumtil,
their several effects cannot be clearly separated ; and when they botli
take place rapidly, the degeneration is apt to lose all likeness to«i>eb
as naturally occur, and to appear as only contributing to the rapid dii-
integration and liquefaction of both the tissue and the inflammiun
product. This appears to be the case in many instances of uloerttion ;
a process which I have deferred to the very end of the history of it
fliimmation, because all the other parts of the disease appear to btl^
gaged in it.
I need hardly say, that, ever since Hunter's time, confudoa ta*
existed in the use of the terms employed for various kinds or mothooi
iif absorption and ulceration. Of all that Hunter wrote, nothing. I
think is so intricate, so difficult, to understand, as his chapter on olotf-
ative inflammation ; and much of the obscurity in which he left the n^
jcct remains. Some of this depends on the same terms having l>N'>
used in different senses, and may be avoided if it is agreed to ipesk «
the removal of those particles of inflamed parte, which are not raU
open or exposed surface, as the "interstitial absorption" of inflw*"
parts. Then, the term " ulceration" may be employed to exprct) ^
removal of the superfldal or exposed particles of inflamed parti; '"'•
rather, when the epithelium or epidermis of an inflniDcd part iHalaitf
removed, it may be called *' abrasion" or " excoriation ;" and whenMj
of the vascular or proper tissue is removed from the surface, it m*/ ^
called " ulceration," If, in such ulceration, the superficial partiel"
may be supposed to be absorbed, the process of removing them ni*J ^
termed " ulcerative absorption,;" but if, as is more probable, their f*"
moval is eflTected entirely by ejecting them from the surface of tk**"
ULCERATION. 289
flamed part, then the term '* ulceration" may sufficiently express this
ejection, and will stand in stronger contrast to the ^interstitial ab-
sorption" of the particles that are not so ejected, but are taken into
the blood.
I have lately referred to the uncertainty whether, as the cavity of an
abscess enlarges or opens, the tissues, and the infiltrated lymph, that
are removed from the inner surface of its boundary walls, are absorbed,
or are disintegrated and mingled with its fluid contents : in other words,
whether they are absorbed or rejected. The same uncertainty exists,
in some measure, in the case of ulceration, concerning which, indeed,
all that was said respecting the necessity of inflammation to the open-
ing of abscesses, might be here repeated, inasmuch as inflammation
seems essential, not only to the formation, but to the extension or en-
largement, of an ulcer. The ulcerative process cannot take place in
healthy tissue ; previous degeneration of the tissue, and that such as
occurs in the inflammatory process, is a condition essential to it.
But when this condition is provided, is the enlargement of an ulcer
effected by absorption of its boundaries, or by the gradual detachment
&nd casting off of particles from their free surface ? Both methods of
enlargement may, perhaps, in some cases, ensue ; but the probabilities
j^re in favor of the enlargement being, as a general rule, effected by the
c^]ection of partiqles.
Thus : 1. Parts to be removed from a surface are generally cast off
jTSther than absorbed, as cuticles of all kinds are, and the materials of
i9«cretions ; so that, by analogy, we might assume that the particles of
^lie surface of a spreading ulcer would also be cast off.
2. The materials of the ulcerating tissue may be sometimes found in
^le discharge from the ulcer. In most cases, indeed, this is impossible ;
^nt perhaps it is so only because, when the tissues, and the lymph pro-
duced in them, are degenerate and broken up, or decomposed and dis-
^^Ived, we have no tests by which to recognize them. In the ulcera-
tion of oartilage, however, in which inflammatory exudation has no
'^lare, the process of ejection of the disintegrated tissue is clearly
traced ; and we might deem this almost a proof of the same process
^ing observed in other tissues, if it were not that in the cartilage a
Necessary condition of absorption, the presence of a circulation, is
Wanting. The same process of ejection, however, is traceable, in ulcer-
ating bone, where absorption might occur. It is shown by the observa-
tions which I have quoted from Virchow ; and Mr. Bransby Cooper
las observed that, while in pus from soft parts only traces of phosphate
of lime are found, the pus from around diseased bone contains in solu-
tion nearly 2| per cent.* A similar but less complete observation had
been made by Mr. Thomas Taylor,t and by v. Bibra ;X and we may
* Medical Gazette, May, 1845.
f Stanley : Treatise on Diseases of the Bones, p. 89.
t Cheroische (Jntersuchungen verschiedener Eiterarten, p. 85.
290 ULCERATION.
believe that at least some of the phosphate of lime in these cases was
derived from the diseased bone.*
3. It strengthens this belief to observe that, in many cases, small
fragments of bone and other tissues are detached, and cast out with the
fluid from the ulcerating part. These, indeed, when they are not frag-
ments of tissue detached by ulceration extending around them, are
good examples of the transition that may be traced from ulceration to
sloughing or gangrene of parts, between which, if ulceration be always
accomplished by ejection, the only essential difference will be one of
degree ; the ulceration being a death and casting off of invisible par-
ticles of a tissue, while gangrene implies the death and casting off of
visible portions.
4. And it may be proved of many that we call ulcers, that they begin
as sloughs, which are cast off, and leave the ulcerated surface beneath.
We may often see this, on a large scale, in the instances of what are
called sloughing ulcers ; but Dr. Baly has proved it for a much wider
range of cases, in his observations on dysentery, in which he has traced
how even the smallest and the most superficial ulcers of the intestine
are preceded by the death and detachment of portions of the mucous
membrane, with its epithelial investment.f
From these considerations we may hold it as probable that ulceration
is, usually, the result of the detachment of dead portions or molecules
of an inflamed tissue, and that the substance removed in the process is
not absorbed but ejected. There are, indeed, some cases which may
make us willing to admit, at present, that all ulceration is by ejection ;
such as those of bone ulcerating under cartilage, or in the rapid exten-
sion of inflammation within it, or such as the spreading ulceration of
the vertebrae, or of the heads of bones, that is not attended with ex-
ternal discharge of fluid. These may, for the present, interfere with
the universality of the rule, but not with its generality.
But, if we may believe that the removal of a tissue by ulceration is
generally effected by ejection of its substance, the question may be
asked, in what form is it ejected ? Dr. Baly's observations enable us
to say that, in the first instance, a visible slough is detached, a portion
of the tissue dying and being disconnected from the adjacent living
* The belief may seem the more reasonable, because of the similar fact of the quick ab-
sorption of bone-earths in inflamed but not ulcerating bones. Still, it must be admitted,
more evidence is needed that the quantity of bone-earths discharged with the pus is pro-
portionate or equal to the quantity lost by the ulcerating bone. For if what has been said (rf
the conformity of the properties of inflammatory and reparative products witli those of the
tissues from which they are produced, be true, then will also pus from diseased bone possess
more bone-earths than pus from any other tissue, even though the bone be not ulcerating.
Granulations upon bone doubtless contain more bone-earths than those on soft parts, and they
may ossify : now the relation of pus to granulations is commonly that of degenerating cells
to the like cells developing ; therefore we might expect that pus from bone, like granulations
from bone, will contain a large proportion of bone-earths, independent of what may be derived
from the ulceration of the bone.
f Gulstonian Lectures: Medical OazeUe, 1847.
ULCERATION. 291
tissue. Bat, after this is done, when an ulcer enlarges, or extends and
spreads, is the material of the tissue still removed in visible sloughs or
fragments ? Certainly it is so sometimes ; for we may find little frag-
ments of bone in the discharge from ulcerating bone, especially in stru-
mous ulceration. But in other cases we have no evidence of this kind ;
we cannot detect even microscopic fragments of tissues in the discharges;
and we must suppose that they are removed, in a state of solution or of
molecular division, in the discharge from the diseased part. *
To speak of the solution of tissues in the discharges of ulcers may
seem like the revival of an old error long since disproved. But though
the expression may be revived, it is with a new meaning. The proof
has, truly, been long completed, that healthy tissues, even though they
be dead, cannot be dissolved in pus, or any such discharge; but the
tissues that bound or form the walls of a spreading ulcer are not
healthy ; they are inflamed, and, as I have been just saying, their ele-
ments, and the products of inflammation in and among them, arejdege-
nerate, so that they may be now minutely divided, or even soluble in
fluids that could not dissolve them while they were sound. Insolubility
is as great an obstacle to absorption as to ejection in discharges ; no
tissue can be absorbed without being first so far changed as to be solu-
ble or very minutely divided in fluids with which it was before in con-
tact and unharmed. Therefore, whether we hold the ordinary spreading
of an ulcer to be by absorption of its boundaries, or ascribe it to their
ejection, we must, in either case, admit that they are first made soluble.
And if this be admitted, then it is most consistent with analogy, and
most probable, that the extension of an ulcer, independently of slough-
ing, is accomplished by the gradual degeneration of the tissues that
form its walls, and by their being either disintegrated and cast off* in
xninute molecular matter, or else dissolved and ejected in solution in
the discharges from the ulcer.
The solution here spoken of is such as may be effected by the fluid
^scharged from any spreading ulcers ; but we may doubt whether all
^discharges from ulcers possess a corroding property, such as Rokitansky
eeems to ascribe to them, and such as he considers to be the chief cause
^f the extension of all ulcers. We may doubt, I say, whether all
"Ulceration can be described as a corrosion or erosion of the tissues by
Schor ; but, on the other side, we cannot well doubt that the properties
f>{ the discharge from an ulcer, or a sloughing sore, may have a great
influence in accelerating the degeneration and decomposition, and
thereby the solution, of the tissues that form its walls or boundaries.
* The observations of Professor Goodsir (op. cit. p. 15), tend to show that the disap-
pearance of the textures of an ulcerated surface is due to the rapid formation of a layer of
celli on the surface and at the margin of the ulcer, which cause the destruction of the nor
mat textures, either by previous solution and subsequent absorption of the latter, or by the
vigprous growth of the cells monopolizing the proper resources of the part, so that it gradu-
ally disaolvefl and disappears.
292 HEALING OP ULCERS.
Many ichoroas discharges from ulcers inflame and excoriate the parts
over which they flow, and thus inflaming them, they promote their de-
generation, and lead them more readily to enter into the ulcerative
process. Many such discharges, also, are in an active state of decom-
position ; and their contact with the inflamed tissues cannot bat have
some tendency to excite decomposition in them ; a tendency which the
tissues will be the less able to resist, in the same proportion as they are
already feebly maintaining themselves, or as they have been moved by
inflammation from their normal conditions and their normal tenacity of
composition.
On the whole, then, we may conclude, respecting the process of
ulceration, that its beginning is usually the detachment of a slough, or
portion of dead tissue, by the removal of the layer of living tissue that
bounded it ; that the spreading of an ulcer, independent of such visible
sloughing, is efiected by the inflamed tissues that bound it becoming
degenerate, and being detached in minute particles, or molecular mat-
ter, or being decomposed and dissolved in the fluid discharge or ichor;
and that this spreading may be accelerated by the influence of the dis-
charge itself, which may inflame the healthy tissues that it rests on,
a^d may exercise a decomposing '^catalytic" action on those that are
inflamed already.
I need hardly say that we have no knowledge by which to explain
the peculiar and characteristic forms of certain ulcers. We seem
wholly without a guide to such knowledge ; but the existence of such
specific forms is conclusive against the supposition that the extension
of an ulcer is entirely due to corrosion by an exuded fluid. Such a
fluid would act uniformly, unless the various effects of disease on the
tissues bounding the ulcer should make them variously amenable to its
influence.
We have as little knowledge of the nature and real differences of the
various fluids discharged from ulcerating surfaces, — the various kinds of
ichor* that they yield. They consist, generally, of fluid exuded from
the surface as an inflammatory product, and holding in suspension or
solution the disintegrated materials of the ulcerating tissue, and of the
lymph infiltrated in them. The inflammatory product exuded on »
spreading ulcer has, indeed, the constituents of lymph or pus ; but they
appear immature or degenerate, consisting of abundant molecular mat-
ter, with flakes of soft, dotted fibrine, and ill-formed lymph- or pus-cells,
floating in an excess of liquid. Such a substance is, probably, always
* I think it would be useful to employ the term ichor exclusively for those diachaige*
mixed with exudation that take place from ulcerating, i.e., from progressively ulcerating or
sloughing surfaces. For, although it may be often impossible to distinguish, by any mini-
fest properties, such ichor from some of the thinner kinds of pus, yet, if the account of
suppuration and of ulceration be true, a constant difference between pus and ichor will
be, that the latter contains disintegrated materials of the ulcerating tissue, the forniei
does not.
NATURE AND CAUSES OF INFLAMMATION. 293
incapable of organization, both becaase of its own defect, and becaase
of the inflamed state of the parts it is in contact with. The differences
that may, from the first, exist in the several examples of ichor are
moreover quickly increased by the various chemical transformations
that they undergo. Rokitansky alone has endeavored to enumerate
the varieties of property that may hence issue, and the influences they
may exercise in the maintenance of the disease.'*'
As from other inflammatory processes, so from ulceration, we may
trace the transitions to the healing process. In the case of ulcerated
cartilage, Dr. Bedfern's researches show that the healing is accom-
plished, mainly, by the complete transformation of the remaining car-
tilage-substance into fibrous tissue. Here is no proper process of
exudation, for here ate no interstitial bloodvessels ; the materials of
the tissue itself, by transformation, form the scar.
But in the vascular tissues, the reparative material is the lymph in-
filtrated in them at and near the boundaries of the ulcer. As the in-
flammation subsides (for here, as in other cases, the inflammation that
prodnced the lymph must cease for its development), the lymph passes
through changes like those described in the abscess-wall, and the tissues
in which it was infiltrated may, perhaps, recover from their degenera-
tion. Part of the lymph, increased by fresh exudation, assumes the
characters of granulations, which, as we watch the progress of an im-
proving ulcer, assume daily more of the characters of those on healing
open wounds. We cannot, indeed, mark the very act, or tell the hour,
at which the inflammatory process was changed for the reparative ; at
^hich the degeneration ceased, and development began ; there are no
l^rf boundary lines here, or in any passage from disease to health ; but
the change is gradually accomplished, and is manifest both in the organi-
sing material of the granulations, and in the pus which takes the place
of the ichor, and exactly resembles that of the healing granulating wound,
^e ulcer is no longer ulcerating, but healing ; and the histories of the
I^ealiDg nicer, and of the healing wound, might be told in the same
Words.
LECTURE XVIII.
NATURE AND CAUSES OF INFLAMMATION.
The several parts of the inflammatory process have been now cen-
tered. They are, — increased fulness of the bloodvessels, with re-
larded movement of the blood ; swelling ; pain, or other morbid exalted
sensation ; increased heat ; exudation of lymph from the bloodvessels ;
defective nutrition of the proper elements of the afiiected part. The
* Patbologiflche Anatomie, B. i, p. 213.
294 NATURE AND CAUSES OF INFLAMMATION.
first five are often spoken of as the signs of inflammation, the last two
as its effects ; but these terms have reference only to the former being
more transitory phenomena than the latter : they are all, when they
concur, constituent parts of the disease ; but the latter are less quickly
recovered from than the former.
It would not be judicious, I think, to refuse to call that process in-
flammation, in which any one of the conditions just enumerated is ab-
sent or unobserved. Swelling, or pain, or, much oftener, increased heat,
may be inappreciable in tissues that we may still rightly call inflamed,
while the other evidences of the disease are present. The same maybe
said of increased or altered exudation from the bloodvessels. No such
exudation is observed in the diseased cornea or articular cartilages ; but
it would be unreasonable, in the case of an inflamed eye, to say that the
changes are due to inflammation in every part but the cornea ; and to
call the process leading to the ulceration or leucoma of the cornea by a
name different from that which we give to the coincident and similarly
excited process in the other tissues. So, during the inflammation of a
joint, it w^ould be, at the least, inconvenient to say that all the tissues
are inflamed except the softening or ulcerating cartilages. The pro-
gressive degeneration of tissue is, probably, never absent when the
other parts of the inflammatory process exist ; but, in quickly transi-
tory cases, it is often inappreciable. The altered state of the circula-
tion may be unobserved : but it is, probably, always present ; for in the
case of the pafts that have no interstitial bloodvessels, inflammation
may still be attended by enlargement of those of adjacent parts on
which their ordinary nutrition depends.
The conclusion, then, may be, that in what may be regarded as well-
marked, or typical examples of inflammation, all the characters I have
enumerated are present as concurrent parts of the disease ; but that the
same name should not be refused to diseases in which any one of these
parts is absent or unobserved, especially when its absence may be
explained, as in the case of inflamed cartilages, by some peculiarity of
tissue or other condition of the disease. I think it would not be right
to call any process inflammation in which there is neither an exudation
of lymph {i. e. of material capable of such developments or degenerations
as I have described), nor a deterioration of a proper tissue of the affected
part ; even though the other characters of the disease might be present
But, really, whatever rule of nomenclature be adopted, we may expect
to meet with many cases in which we shall doubt what name to give to
the processes which we watch, or of which we see the results. There
is neither here, nor in any other part of pathology, anything like the
unity, or circumscription, of species by which the zoologist, whose
nomenclature pathologists are prone to imitate, is justified in attaching
to each specific name the idea of several constant and unalterable cha-
racters in the beings to which it is assigned.
NATURE AND CAUSES OF INFLAMMATION. 295
An ezamination of the very nature of the process of inflammation
may best be made in the form of a comparison of its effects with those
of the normal process of nutrition. And this comparison may be drawn
with two principal views ; namely, to determine — 1st, how the effects
of inflammation differ, in respect of quantity^ from those of the normal
process ; and 2d, how they differ from the same, in respect of quality
or method.
The decision on the first of these points may seem to be given in the
term *' increased action," which is commonly used as synonymous with
inflammation. As used by Mr. Hunter, this term was meant to imply
that the small vessels of an inflamed part are more than naturally active,
in formation or absorption, or in both these processes. This is, proba-
bly, the meaning still generally attached to the term by some ; while,
as employed by those who believe the vessels are only accessories in the
work of nutrition, the expression "increased action" may be used to
imply merely increased formation, or increased absorption. In either,
or in any, meaning, however, the term seems to involve the idea of an
increased exercise of vital forces, i. e. of those forces through the opera-
tion of which the various acts of organic formation are accomplished.
But, if " increased action" is to imply this, the description of the process
and effects of inflammation shows that the term cannot be properly used,
^thout some limit or qualification.
If we consider the quantity of organic formation effected during the
inflammatory process, in the proper substance of the inflamed part, it
is evidently less than in health. All the changes described in the last
lecture are examples of diminished or suspended nutrition in the tissues
of the inflamed part : they are all characteristic of atrophy, degenera-
tion, or death. The tissues become soft, or quite disorganized ; they
*re relaxed and weakened ; they degenerate, and remain lowered at once
w stmcture, chemical composition, and functional power ; or else, after
degeneration, they are absorbed, or are disintegrated, or dissolved, and
c»8t out; they die in particles or in the mass. During all the processes
of inflammation there is no such thing as an increased formation of the
natural structures of the inflamed part ; they are not even maintained ;
Aeir nutrition is always impaired, or quite suspended. It is only after
fte mflammation has ceased that there is an increased formation in
some of the lowly organized tissues, as the bones and connective tissue.
So far, then, as the proper substance of the inflamed part is con-
cerned, there appears to be decreased action ; that is, decreased forma-
tion. There may be, indeed, an increased absorption ; but this is also, in
one sense, characteristic of decreased exercise of vital force ; since all
absorption implies a previous degeneration of the part absorbed. Nor
can we justly call this, in any sense, '^ increased action," till we can show
how absorption is an action of vessels.
Thus far, one of the constituents of the inflammatory process, one of
296 NATURE AND CAUSES OP INFLAMMATION.
the characters in which it differs, in respect of quantity, from normal
nutrition, is a defect in the nutrition of the proper substance of the
inflamed part.
But it is characteristic of the complete process of inflammation, that,
while the inflamed structure itself suffers deterioration, there is a pro-
duction of material which may be peculiarly organized. Here, there-
fore, may be an evidence of increased formation, of increased action.
Doubtless in relation to the productive part of the inflammatory pro-
cess, the expression " increased action" may be in some sense justly used ;
for the weight of an inflamed part, or of the material separated from it^
may be much increased by the formation of organized matter. But the
quantity of organized matter formed in an inflammation must not be
unconditionally taken as a measure of increase in the exercise of the
vital forces; for it is to be observed, that the material formed presents
only the lowest grades of organization, and that it is not capable of
development, but rather tends to degeneration, so long as the inflam-
mation lasts.
It may be but a vague estimate that we can make of the amount of
force exercised in any act of formation ; yet we may be sure that a
comparatively small amount is suflScient for the production of low organ-
isms, such as are the fibrinous and corpuscular lymphs of inflammation.
The abundant production of lowly organized structures is one of the
features of the life of the lowest creatures, in both the vegetable and
animal kingdoms. And in our own cases, a corresponding abundant
production is often noticed in the lowest states of vital force ; witness
the final inflammations, so frequent in the last stages of granular de-
generation of the kidneys, of phthisis, of cancer, and other exhausting
diseases. In all these, even large quantities of the lowly organized
cells of inflammatory lymph may be formed, when life is at its last ebb.
And with these cases those correspond which show the most rapid in-
crease of tubercle and cancer, and of lowly organized tumors, when the
health is most enfeebled, and when the blood and all the natural struc-
tures are wasting.
From these considerations we may conclude that the productive part
of the inflammatory process is not declaratory of the exercise of a large
amount of forn^ative or organizing force ; and this conclusion is con-
firmed by observing that development, which always requires the
highest and most favored exercise of the powers of organic life, does
not occur while inflammation lasts. The general conclusions, therefore,
may be, as well from the productive as from the destructive, effects of
the inflammatory process, that it is accomplished with small expenditure
of vital force ; and that even when large quantities of lymph are lowly
organized, such an expression as " increased action" cannot be rightly
used, unless we can be sure that the defect of the formative power, ex-
ercised in the proper tissue of the inflamed part, is more than counter-
NATURE AND CAUSES OF INFLAMMATION. 297
balanced by the excess employed in the production and low organization
of lymph.
It may be said that the signs of inflammation are signs of increased
action. But these are fallacious, if, again, by increased action be meant
any increased exercise of vital force. The redness and the swelling
of the inflamed part declare the presence of more blood ; but this blood
moves slowly ; and it is a quick renewal of blood, rather than a large
quantity at any time in a part, that is significant of active life. An
abundance of blood, with slow movement of it, is not characteristic of
activity in a part ; it often implies the contrary, as in the erectile tis-
sues, and the cancellous tissue of bone.
The local increase of heat is too inconstant to afford ground for judg-
ing of the nature of inflammation.'*' When manifest, it is not, I think,
to be exactly compared with that of an actively growing part, or of one
which is the seat of " determination*' of blood, or of " active congestion."
In these cases the heat is high chiefly because the blood, brought quickly
from the heart, is quickly renewed ; but, in an inflamed part, the blood
is not 80 renewed ; it moves more slowly. The heat may, indeed, be in
some measure ascribed to this condition ; for the quickly moving blood
around the inflamed part may communicate its heat to that which is
moving more slowly. But the proper heat of inflammation (I mean that
which is measurable by the thermometer), cannot, I think, be wholly
thus explained. Some of it is, probably, due to the oxidation of the
degenerating tissues ; a process which we might safely assume to be
rapidly going on in the more destructive inflammatiohs, and which is,
indeed, nearly proved by some of the evidences of the increased excre-
tion of oxidized substances in inflammations, especially by the increase
of phosphates in the urine during inflammation of the brain, f It is far
from proved, indeed, that this source of heat is sufficient for the expla-
nation of the increase in an inflamed part ; and it may be at once ob-
jected that we have no evidence that the hottest inflamed parts are
those in which the most destructive processes are going on. Still, in
relation to the question, how far the increased heat is a. sign of the
quantity of formative force that is being exercised, we may argue that,
as the general supply of heat in our bodies is derived from oxidation
or combustion of wasted tissues or of surplus food, so in these local
augmentations of heat, the source is rather from similar destruction of
organized substances than from increased formation of them. If it be
80, the increased heat will give no ground for regarding the inflamma-
tory process as the result of a greater exercise of formative force than
is employed in ordinary nutrition ; none for speaking of it as increased
nutrition or increased action. Rather, this sign may be added to the
* See, especially, t. BbrensprQng in Milller's Arcbiy, 1852, p. 268.
t Dr. Benoe Jones: On the contrast between Delirium Tremens and Inflammation of the
Brain, MecL-Chir. Trans, vol. xxx, p. 37 j and Virchow, in his Archiv, B. iv, H. 1.
20
298 NATURE AND CAUSES OF INFLAMMATION.
evidences, that the inflammatory process presents, of diminished forma-
tive force, and of a premature and rapid degeneration, in the affected
part.
In thus endeavoring to estimate the difference between the normal
and the inflammatory modes of nutrition in regard to the quantity of
formative or other vital force exercised in them respectively, I have
also stated the chief differences in relation to the quality or method of
nutrition.
The most general peculiarity of the inflammatory method is the con-
currence of the two distinct, though usually coincident, events of which
I have spoken at such length ; namely, 1st, the impairment or suspen-
sion of nutrition of the proper substance of the inflaped part ; and 2d,
the exudation, from the blood, of a material more than sufficient in
quantity for the nutrition of the part, but less than sufficient in its
capacity of development.
By these concurring, it is plainly distinguished from the normal
method of nutrition. The same combination of events establishes the
chief differences between the inflammatory and every other mode of
nutrition in a part. Thus, from all the forms of mere atrophy or de-
generation, the inflammatory process, at least in the typical examples,
is distinguished by the production of the lymph, which may be organ-
izing, even while the proper tissue of the inflamed part is in process
of atrophy, degeneration, or absorption. So far as the tissues inflamed
are concerned, some inflammations might be classed with atrophies or
degenerations ; but the concurrent production of lymph is distinctive
of them.
On the other side, the inflammatory mode of nutrition is distin-
guished from hypertrophy by the failure of the nutrition of the in-
flamed part itself. So far as mere production and formation of organ-
isms are concerned, some inflammations might be paralleled with
hypertrophies ; but the organization of the lymph commonly falls short
of that proper to the part in which it is exuded ; and the substance of
the part, instead of being augmented, is only replaced by one of lower
organization.
And, lastly, from the production of new growths, such as tumors,
the inflammatory process is distinguished by this, — that its organized
products, though like natural tissues of the body, are usually infiltrated,
fused, and interwoven into the textures of the inflamed part ; and that,
when once their development is achieved, they have no tendency to in-
crease in a greater ratio than the rest of the body.
I am well aware that these can be accepted as only the generally
distinguishing characters of the complete inflammatory process. Cases
might be easily adduced in which the border lines are obscured ; in-
flammations confounded on one side with atrophies, on another with
hypertrophies, on a third with tumors, and on others, with yet other
NATURE AND CAUSES OP INFLAMMATION. 299
local phenomena of disease. But the same difficulties are in every
department of our science ; yet we must acknowledge the value of
general distinctions among diseases even more alike than these are.
The case that I have chosen for illustrating the general nature of the
imflammatory process is one representing the disease in its simplest
form and earliest stage, manifesting only the formation of lymph, and
such a change as the softening or absorption of the inflamed part. This
is but the beginning of the history : but, if the inflammation continues,
or increases, in severity, all that follows is consistent with this begin-
ning ; all displays the same double series of events, the same defective
nutrition of the part, and the same production of low organisms. But
these additions are observed : the part is more and more deteriorated,
and perishes in the mass, or in minute fragments ; the newly-organized
products, not finding the necessary conditions of nutrition, partake in
the degenerative process, and, instead of being developed, are degene-
rated into pus, or some yet lower forms, or perish with the tissues in
which they are imbedded.
Respecting now the causes of inflammation, I shall not say more of
its exciting causes than that from the external ones, which alone we
can at all appreciate, we may derive a confirmation of the opinion I
have expressed concerning the nature of the process. They are such
as would be apt to produce depression of the vital forces in a part ; all
being, I think, such as, when applied with more severity, or for a longer
time, lead, not to inflammation, but to the death of the part. If a cer-
tain excess of heat will inflame, a certain yet greater heat will kill : if
some violence will inflame, a greater violence will kill : if a diluted
chemical agent will only irritate, the same concentrated will destroy the
part. The same may be said, I think, of cold, and all the other external
exciting causes of inflammation. I am aware that other explanations
of their action are given ; but none seems to me so simple, or so consis-
tent with the nature of the process that follows them, as this which
assumes that they all tend (as it may be said) to depress the vital forces
exercised in the affected part. They may be stimulants or excitants of
the sensitive nerves of the part, but they lead to the opposite of ac-
tivity in its nutritive processes. In the reaction which follows the appli-
cation of some of them, they may seem to have been the excitants of
nutritive action ; but, if the inflammatory state ensue, the formative
process, we have seen, is really diminished.
The proximate causes, or immediately preceding conditions, of in-
flammation appear to be various perversions of the necessary conditions
of healthy nutrition in a part ; that is, morbid changes in either the
supply of blood, the composition of the blood, the influence of the ner-
vous force, or the condition of the proper substance of the inflamed
part. Any one or more of these four conditions of nutrition being
changed in quality may initiate an inflammation. A change in quantity
300 NATURE AND CAUSES OF INFLAMMATIOH.
more usually produces either an excess or deficiency of nutrition in the
part, or some process different from inflammation. Thus, a diminution
or withdrawal of the blood, without alteration of its quality, is usually
followed by atrophy, degeneration, or death : a mere increase of blood
in a part may produce hypertrophy, or something more nearly resem-
bling inflammation, yet falling short of it. Similar effects may ensue
from a mere increase or decrease, or abstraction, of nervous force.
Change in the quality, whether with or without one in the quantity, of
the conditions of nutrition, appears essential to the production of the
phenomena of inflammation.
I will endeavor now to show that inflammation may follow such per-
version or qualitative change in each of the conditions of nutrition,
even though all the rest of them remain for a time in their normal
state : selecting, for this purpose, such cases of inflammation as we may
trace proceeding, in the first instance, from the uncomplicated error of
a single condition of nutrition.
I. Inflammation may perhaps be produced, — it certainly may be
commenced, and in some measure imitated, — by changes in the blood-
vessels ; changes attended with alteration of their size, or their permea>
bility, or the other qualities by which they affect the supply of blood
to a part. This may be concluded from the similarity to some of the
phenomena of inflammation which may be observed in certain cases of
mechanical obstruction to the venous circulation. In a case of ascites
from diseased heart or liver, the peritoneum often contains coagula of
fibrine floating free in the serum, though no organ may present appear-
ances of having been inflamed. In such a case, moreover, I have found
the fibrine developing itself in the form of nucleated blastema, even
while 'floating free. In another case of mechanical dropsy, I have found
the fluid of anasarca in the scrotum containing both fibrine and abun-
dant lymph-corpuscles, like those in the fluid of an inflammatory exu-
dation. In like manner an apparently uncomplicated obstruction at
the left side of the heart may produce many of the phenomena of
bronchitis. Such as these are the cases through which mechanical con-
gestions of blood connect themselves with inflammation. And if to
these we add the constancy of increased vascularity among the phe-
nomena of inflammation, they may be sufficient to make us believe, that
disturbances in the circulation of a part may produce some of the prin-
cipal phenomena of inflammation, even though all the other conditions
of nutrition are, in the first instance, unchanged. But I know no other
good evidence for the belief; and I think we should not lay much stress
on these cases, since they display an imitation of only some parts of
the process of inflammation ; namely, the fulness of the vessels, the re-
tarded blood, and the exudation of organizable matter. The nutrition
of the proper tissues of a part with merely obstructed circulation suffers
but a trivial loss or disturbance, in comparison with that which would
NATURE AND CAUSES OF INFLAMMATION. 301
accompanj an inflammation with an equal amount of retardation in the
movement of the blood. So far as the exudation in an inflamed part
depends on the altered mechanical relations of the blood and vessels,
so far may similar alterations alone produce efiects imitating those of
inflammation ; they may also be the beginning of the more complete
process ; but I believe that the merely mechanical disturbances of the
circulation are no more adequate alone to the explanation of the whole
process of inflammation, than the normal movements of the blood are
adequate to the explanation of the ordinary process of nutrition.*
II. We may speak much less equivocally of the influence of the state
of the blood itself in causing inflammations ; for there can be little
doubt that a very great majority of the so-called spontaneous or con-
stitutional, as distinguished from traumatic inflammations, have herein
their origin. We might anticipate this, from the consideration that, in
normal nutrition, the principal factors are the tissues and the blood in
their mutual relations : but we have better evidence than this, in cases
of local inflammations occurring in consequence of general diseases of
the blood. Some instances of this are clearly proved, as, e. g. in the
cases of eruptive fevers, when the presence of morbid materials in the
blood is proved by the efiects of their transference in inoculation.
Scarcely less thoroughly demonstrated are the cases of rheumatism
and gout, of lepra, psoriasis, herpes, eczema, erysipelas, and other
such a^ections, whose constitutional nature, — in other words, whose
primary seat in the blood, — all readily acknowledge in practice, if not
in theory.
Now, in all these cases, local inflammations are the external signs of
the general aficction of the blood ; and I apprehend, that if any diflS-
culty be felt in receiving these as evidences that the morbid condition
of the blood is the cause of the local inflammation, it will be through
doubt whether a general disease of the blood — a disease afiecting the
blood sent to every part — can produce peculiar phenomena of disease
in only certain small parts or organs. But this local efiect of a gene-
ral disease of blood has its illustration in some of the sure principles of
physiology ; especially in one which I have fully illustrated in a former
lecture (p. 40 et seq. and p. 63) ; namely, that the presence of certain
materials in the blood may determine the formation of appropriate or-
ganisms, in which they may be incorporated.
It is in exact parallel with the facts in physiology which I then ad-
duced, that in certain general diseases of the blood, organs are formed,
as the products of inflammation, within which the specific morbid mate-
rial is incorporated. Thus, in small-pox, cow-pox, primary syphilis,
* The ezperimenta by Cl. Bernard and others, alluded to on p. «^2, conclusively show
that great bypersmia and increased redness and temperature may occur in a part, under
eertaio conditions, without being accompanied by any of the other evidences of inflamma-
tioD.
302 NATURE AND CAUSER OF INFLAMMATIOH.
and whatever other diseases may be transferred by inoculation, the
morbid material from the blood is incorporated in the products of inflam-
mation, which are inclosed within the characteristic vesicle or pustule,
or infiltrated lymph, just as, in the cases already cited, the constituents
of urine or of medicines are incorporated in the renal cells, which are
formed within the substance of the kidney ; or just as the constituents
of sap are incorporated in fruit.
In the cases of disease produced by a demonstrable virus, we have
all the evidence that can be necessary to prove the principle, that a
general disease of the blood may be the cause of a local inflammation
in one or more circumscribed portions of a tissue. And the analogy is
so close, that I think we need not hesitate to receive the same explana-
tion of other inflammations, which I have cited as occurring during mor-
bid conditions of the blood. For although we cannot, by inoculation,
prove that a specific morbid material of such a disease as herpes or
eczema, gout or rheumatism, has been incorporated in the inflammatory
products, yet we find great probability hereof in the many analogies
which these diseases present to the inoculable diseases, in their whole
history, and, especially, in the decrease or modification of general illness
which ensues on the full manifestation of the local inflammation. -
If it be asked why a morbid material is determined to one part or
tissue rather than another, or why, for example, the skin is the normal
seat of inflammation in small-pox, the joints in rheumatism, and so on,
I believe we must say that we are, on this point, in the same ignorance
as we are concerning the reason why the materials of sweat are dis-
charged at the skin, those of urine at the kidneys, of bile at the liver,
or why the greater part of the albuminous principles are incorporated
in the muscles, and of the gelatinous in the bones. We cannot tell why
these things are so, but they are familiar facts, and parallel with what
I here assume of the incorporation of morbid materials derived from
the blood.
Again, it may be said that we need some explanation of the fact that
the morbid condition of the blood does not influence the whole extent
of any given tissue, but only portions of it. In the secretion of urine,
it may be believed that the whole kidney is afiected and works alike ;
but in the assumed separation of the virus of small-pox, only patches
of the skin are the seats of pustules ; in vaccinia and primary syphilis,
only a single point ; in secondary and tertiary syphilis, a certain, but
sometimes disorderly, succession of various parts ; and so on.
It must be admitted that many of the facts here referred to cannot
yet be explained. In some cases, however, we can assign, with much
probability, the conditions that determine the locality in which a general
disease of the blood will manifest itself by inflammation. In some in-
stances, it is evident that the localization is determined by such as we
may call a weakened or depressed condition, a state of already impaired
nutrition, in some one part. For instance, when a stream of cold air
NATURE AND CAUSES OF INFLAMMATION. 303
is impelled on some part, say the sbonlder, of a person disposed to rheu-
matism, it determines, as a more general exposure to cold might do in
the same person, the rheumatic state of the blood with all its general
symptoms : but it determines, besides, the part in which that rheumatic
state shall manifest itself first or alone. The depressed nutrition of the
chilled shoulder makes it more liable than any other part to be the seat
of inflammation excited by the diseased blood.
Or, again, when a virus is inserted, as in all cases of poisoned wounds,
the local inflammation produced by the disease with which the whole
blood is infected will commonly have its seat in the wounded part.
The virus must have produced some change in the place in which it
was inserted, as well as in the whole mass of the blood. The change
is not merely that of a wound ; for a simple wound made in the same
person, at the same time, will not similarly inflame ; it is a change due
to the direct influence of the virus. And the part thus changed may
long remain in a peculiar morbid state, and peculiarly prone to inflam-
mation from diseased blood. Thus, an infant was vaccinated in the
middle of June, and the disease had its usual course ; six ordinary vesi-
cles formed in the punctures in the left arm, and common cicatrices re-
mained, and all appeared well. In the middle of July, inflammation of
the left axillary glands ensued. When I saw the child on August 21st,
the glands were very large, and partially suppurated, and there was
extensive inflammation of the skin of the upper arm. On August 30th,
the pus having been partially discharged by incision, the glands had
subsided, but superficial inflammation of the integuments existed still,
and now there was, on the middle of each vaccine cicatrix, a distinct
circular low vesicle, not unlike that of the true vaccine eruption, ex-
cept that it was not umbilicated, and appeared to have an undivided
cavity.
Such cases are, probably, only examples of a general rule, that a
part whose natural force of nutrition is in any way depressed, is, more
than a healthy part, liable to become the seat of chief manifestation of
a general blood-disease. A part that has been the seat of former dis-
ease or injury, and that has never recovered its vigor of nutrition, is
always so liable ; it is a weak part. Thus, the old gouty or rheumatic
joint is apt to receive the brunt of the new attack. And the same may
happen in a more general way. A man was under my care with chronic
inflammation of the synovial membrane of his knee, and general swell-
ing about it ; he was attacked with measles, and the eruption over the
diseased knee was a difiused bright scarlet rash. A patient under Dr.
Budd*)s care had small-pox soon after a fall on the nates : the pustules
were thinly scattered everywhere, except in the seat of former injury,
and on this they were crowded as thickly as possible. Thus, too, when
a part has been injured, and, it may be, is healing, a disease having
bc^gun in the blood will manifest itself in this part. Impetigo appears
304 NATURE AND CAUSES OF INFLAMMATION.
about blows and scratches in nnhealtkj children ; erysipelas adoat the
same in men with unhealthy blood.
Such are some of the cases in which we seem able to explain the ap-
parent choice of locality for inflammation, made by a morbid material
which is diffused through all the blood. Many remain unexplained ;
if it were not so, this portion of pathology would be a singular excep-
tion to the general condition of the science. But these difficulties
afford no warrant for the rejection of a theory, of which the general
probability is affirmed by so many analogies, by the sufficiency of its
terms for the expression of the facts, and, it may be added, by nearly
every 'particular in the constitutional treatment of local inflammation.
For, I suppose there are few parts of the medicinal treatment of local
inflammation, for which any reason can be shown, unless it be assumed
that the medicine corrects some morbid condition of the blood.
Let it be added that the state of the blood may, in part, or chiefly
determine, not only the locality, but also the degree and form of the
inflammation. It may, as Dr. Ormerod has well expressed it, ** imprint
on the morbid product (of inflammation) certain tendencies which take
effect after the morbid products have entered upon a condition of com-
paratively independent existence.*** But on this point I need not dwell ;
for a large portion of Lecture XIV is devoted to it, and it will be again
considered in the Lecture on Specific Diseases.
III. To test the influence of a disturbance of the nervous force in
engendering the inflammatory process, we must not, as is commonly
done, take cases of the effects of external injury. Such an injury, or
the presence of a foreign body, is supposed to excite inflammation by
stimulating the nerves of the part, and by changing, through their influ-
ence, the state or action of the bloodvessels. This may be true ; but we
should remember that when a common injury is inflicted, it acts not only
on the nerves of the part, but also on its proper tissues ; and it may
so affect the state of these tissues that the changes produced in them
may be the excitant of inflammation, independent of the affection of the
nerves. All such cases as these are, thus, ambiguous.
For a better test, we must select cases in which the excitant of in-
flammation acts (at least in the first instance) on the nervous system
alone. Such cases are those already referred to (p. 225). When the
conjunctiva is inflamed after overworking of the eye, we cannot sup-
pose that the light, by its direct contact, has affected the vessels, or the
nutritive act, in the conjunctiva : it can, probably, affect either of these
only through an influence reflected from the retina. So, when irritation
of the urethra excites inflammation in the testicle; when the irritation
of teething excites it in any distant part ; when, as in a case quoted
from Lallemand, by Dr. Williams, inflammation of the brain followed
* In his lectures on the Pathology and treatment of Valvular Disease of the Heart, in the
Medical Gazette, 1851.
NATUBE AND CAUSES OF INFLAMMATION. 305
the application of a ligature to part of the brachial plexns ; in these
and the like cases we cannot but refer to the disturbance of the nervous
force as the initiator of the phenomena of inflammation.
Now, for the explanation of such cases as these, there appear to be
two chief theories: 1. It may be that the nerves distributed to the
minute bloodvessels of a part may be so affected that these vessels may
dilate, and their dilatation may produce the other phenomena of inflam-
mation ; or, 2. The disturbance of the nervous force may more directly
interfere with the process of nutrition, inasmuch as this force exercises
always some influence in the nutrition of each part, and is (as one may
say) among the plasturgic forces (p. 48).
The first of these theories has lately acquired a dominant place in
systems of pathology, especially in those of Germany. The principal
form of it, which has been maintained most prominently by Henle, has
enlisted the approval of even Rokitansky, and is largely received, pro-
fessing to explain all inflammations, and passing by the name of
"neuro- pathological," to distinguish it from the "humoral," and all
other theories of inflammation. This theory may be thus briefly stated.
The exciting cause of inflammation, whether an external cause, such as
an injury of a part, or an internal one, such as diseased blood, acts, in
the first instance, on the sensitive, centripetal, or afferent nerves of the
part. These it affects as a stimulant, producing in them an excited
state, which state, being conveyed to some nervous centre, is thence
reflected on the centrifugal or motor nerves of the bloodvessels of the
same, or some other related part. This reflection, however, is supposed
to bring about a kind of antagonistic sympathy, such that, instead of
exciting the motor forces of the bloodvessels to make them contract, it
paralyzes them, and is followed by their dilatation or relaxation. This
dilatation being established, the exudation and other phenomena of in-
flammation are assumed to follow as natural, and most of them as
mechanical, consequences.
The eminence of those who have supported this hypothesis makes
one hesitate in rejecting it ; and yet I cannot help believing it to be
groundless. If we remember that parts may present some of the chief
phenomena of inflammation, though they have no nerves, as the firmest
tendons and articular cartilages ; that the degrees of inflammation in
parts bear no proportion to the amounts of pain in them when inflamed ;
that the severest pains may endure for very long, periods with only
trivial, if any, phenomena of inflammation ; that the phenomena of the
so-called reflex paralysis are rare, equivocal, and altogether insufficient
for the foundation of a law or general principle ; we may well think
that there can be no sufficient ground for the invention of such an
hypothesis as this. And, if we add that, even admitting the dilatation
of bloodvessels as a possible consequence of the stimulus of sensitive
nerves, yet the phenomena of even simple inflammation would be no
necessary consequence thereof; that the varieties of inflammations
306 NATURE AND CAUSES OF INFLAMMATION.
would be quite unintelligible as results of similar mechanical disturb-
ances of the circulation ; and that the dilatation of bloodvessels, in any
mechanical way produced, is followed by only feeble imitations of a
part of the inflammatory process ; then we may think that the hypo-
thesis, if all its postulates be granted, will yet be insufficient for the
explanation of the facts.
I believe that, if we would have any clear thoughts respecting the
influence of the nerves in initiating inflammations, we must first receive
the theory already referred to (p. 48 and p. 224), that a certain exer-
cise of the nervous force is habitually and directly engaged in the act
of normal nutrition. If we admit this, there can be little difficulty in
believing, whatever there may be in explaining, that the perturbations
of the nervous force may engender the inflammatory mode of nutrition
more directly, than by first paralyzing the bloodvessels of a part. We
attain nearly to a proof of this in the instances of altered nutrition
adduced in a former lecture (p. 49), and in those of secretions altered,
not in quantity alone, but in quality, by afiections of the nervous
system. It is almost inconceivable that any of the essential properties
of a secretion should be changed by an alteration in the quantity or
movement of the blood in a gland : yet such changes are frequently
manifest in the milk, tears, urine, and sweat, under the influence of
mental afi'ections of the nervous force ; and the analogies of secretion
and nutrition give these cases nearly the weight of proof in the ques-
tion of the influence of the disturbed nervous force in causing inflam-
mations.
IV. The last of the necessary conditions of normal nutrition in a
part is the healthy state of the part itself; and it appears highly pro-
bable that a disturbance of this may initiate, and, in this sense, be the
cause of inflammation. This is probably for many reasons ; and, first,
from analogy with normal nutrition. Generally, the principal condi-
tions of nutrition are in the relative and mutual influences of the
elements of the tissues and the blood. More particularly, the state of
the tissues determines, at least in great measure, both the quantity and
the rate of movement of the blood supplied to them ; the changes of
the tissues, whether in growth or decrease, usually just preceding the
adapted changes in the supply of blood (p. 67). So, we may believe, a
change in a part, anyhow engendered, may, by altering its relation to
the blood, alter its mode of nutrition, and some of the changes may
produce the inflammatory mode of nutrition, together with the altered
supply of blood, and other characteristic signs.* I am disposed to
think such changes would be especially efiective, as causes of inflamma-
tion, when they ensue in the rudimental and still developing elements
of the tissue ; for, as it seems to be chiefly these which determine the
* See as confirming this statement the observations of Prof. Lister, quoted in the notes to
pp. 223, 227.
NATUKE AND CAUSES OP INFLAMMATION. 307
normal supply of blood in a part, so, probably, the abnormal state of
them would most affect that supply.
Secondly, we may judge the same from the analogy between inflam-
mation and the process of repair. Certainly it is the state of the
injured part, t. e. of its proper tissues, not of its nerves and blood-
vessels, which initiates the processes of repair. Now, some of these
are so like those of inflammation, that they are commonly identified,
and are not capable of even a refined distinction. This is especially
the case with the articular cartilages, and the cornea.*
And thirdly, the influence of the condition of the proper tissues of a
part in initiating inflammation in it, is illustrated by more direct facts;
such as, that injuries of parts that have no vessels or nerves are fol-
lowed by altered modes of nutrition which are more or less exact
resemblances of inflammation. Thus, e. g. it is in the lens, vitreous
humor, and the like, after injury. In all of these, it is difficult to ima-
gine any other cause of inflammation than the altered relations between
the tissue and the blood or the materials derived from it.
On the whole, therefore, I think we may conclude that inflammation
may have its origin in disturbance of the normal condition of the pro-
per tissues of a part ; in such a disturbance as may be produced by
injury, or by the proximity of disease.. To this source, indeed, I should
be disposed to refer nearly all inflammations that originate in the direct
application of local stimuli, whether mechanical or chemical. It is true,
that, in most cases, the stimulus affects at once the proper elemeifts of
the part, its nerves, and its bloodvessels, so that we cannot say how
much of the disease is to be ascribed to the affection of each ; but the
fact that a process, resembling, so far as it goes, that of inflammation,
may ensue after injury in parts that have neither vessels nor nerves,
may make one believe that, in parts that have both, the inflammation
depends mainly on injury, or other affection, of the proper tissue.
I have thus endeavored to show that inflammation may take its rise,
may have its proximate cause, in a disturbance of any one of the con-
ditions of nutrition. In the examination of different cases, we find
that, even while any three of the four chief conditions may be normal,
yet a qualitative error of the fourth may bring in the phenomena of the
bflammatory process. In the necessity of choosing pointed cases, I
may seem to have implied that it is usual for inflammation not only to
begin, but to be maintained, by an error in one of the conditions of
nutrition : but this is improbable. Rather we may believe, that many
* See Dr. Redfern^s Researches, I. c. ; and compare Mr. Bowman^s account of the heal-
ii^ of wouods in the cornea, in his Lectures on the Parts concerned in Operations on the
Eye, p. 29, with the observations already quoted from Virchow. The doctrine of the Cel-
lolar Pathology as illustrated by Virchow is based exclusively on the state of the tissues.
The action of irritants on a part being ascribed to the effects produced by them upon the
eiements of the tiasaes directly, and not through the nerves or bloodvessels.
308 NATURE AND CAUSES OF INFLAMMATION.
of the excitants of inflammation may affect at once more than one of
these conditions ; and, as I stated in the first lecture on the subject, it
is nearly certain that in every inflammation, after a short continuance,
all the conditions of the nutritive process are alike involved in error.
The following are references to some of the recent essays on inflammation, from which
the reader, if he have learned the main principles concerning the disease from some of the
classical works upon it, — such as those of Hunter, Thomson, Alison, or Gendrin, — may
gather the best facts and guidance for future inquiry.
J. Hughes Bennett: On Inflammatiori as an Anormal Process of Nutrition. Edinburgh,
1844. — Lectures on Clinical Medicine, 3d ed. 1859.
Bruecke (as quoted by Lebert) : Bemerkungen fiber Entziindung ; in the Sitzungsberichte
der Wiener Akademie. June and July, 1849.
Carpenter : In an article in the British and Foreign Medical Review, vol. xviii, p. 91.
July, 1844.
Andrew Clark : In the Medical Gazette, vol. xlii, p. 286; and in subsequent numbers.
Gluge : Pathologische Histologie, 4to. .Tena. 1850.
Henle : Rationelle Pathologic, B. i. And in his Zeitschrifl, especially the 2d volume.
G. M. Humphry ; Lectures on Surgery ; in the Provincial Medical and Surgical Journal,
1849, and following years.
Wharton Jones : On the State of the Blood and Bloodvessels in Inflammation ; in Guy's
Hospital Reports, vol. vii. 1851.
Kiiss (as oAen quoted by Lebert and Virchow) : De la Vascularity et de Tlnflammation.
1846.
Lebert : Physiologie Pathologique.
Redfern: Anormal Nutrition in Articular Cartilages. Edinburgh, 1850. And especially,
in an Appendix to a Paper in the Monthly Journal of Medical Science, Sept 1851.
Reinhardt : Ueber die Genesis der mikrosk. Elemente in den Entziindungsproducten ;
inTraube's Beitrage, H. li, 1846.
Rokitansky : Pathologische Anatomic, B. i.
Simon : Lectures on General Pathology. In the Lancet, 1850 ; and, collected, 8vo. London,
1850. Article Inflammation in Holmes's System of Surgery. 1860.
Travers: Physiology of Inflammation and the Healing Process, 8vo. 1844.
Virchow: Essays in the 1st and 3d, and especially in the 4th volumes of his Archiv fiir
Pathologische Anatomic. And in the 1st volume of the Verhandlungen der phys.-med.
GesellschaA in Wiirzburg. Cellular Pathologic, 1858.
H. Weber : Experimente iiber die Stase in der Froschschwimmhaut, in Miiller's Archiv, H.
iv, 1852.
C. J. B.Williams: Principles of Medicine, 8 vo. 1843and 1848.
Lister: Philos. Trans., part 2, 1858. On the Early Stages of Inflammation.
Billroth : Beitrage zur Path. Histologie. 1858. Berlin.
C.O.Weber: Die Entwicklung des Eiters. Virchow's Archiv. 1859.
The process of inflammation, so far as it can be illustrated by specimens, may be fully
studied in the Museum of the College, in the preparations Nos. 71 to 129, and in those which
are referred to after the descriptions of these in the 1st volume of the Pathological Catalogue.
Many of the facts relating to the state of the bloodvessels, also, are illustrated by the micro*
scopic specimens in the same Museum. All the best illustrations of the process, in the Mu-
seum of St. Bartholomew's, may be studied by the references in the Catalogue, vol. i, p. xii.
MORTIFICATION. 809
LECTURE XIX.
MORTIFICATION.
Bt Mortification, or Sphacelus, is meant the death of any portion of
the body, while the rest remains living. The term "gangrene" is com-
monly used in the same sense ; " necrosis" for similar death of portions
of bone or cartilage, or, in some recent writers, of any other tissue ;
"necramia" for a corresponding death of the blood. The dead piece
of tissue is called a "slough," or, if it be bone, a " sequestrum." The
process of progressive dying is commonly called " sloughing," a term
which is, however, also applied to the process by which a slough is
separated, with the same meaning as "exfoliation" is used for the pro-
cess of separating a "sequestrum" or dead piece of bone. None of
these terms, however, are used unless the portions of dead tissue be visi-
ble to the naked eye. It is probable that what is ejected from the tis-
sues in the ulcerative process is quite dead ; but, so long as it is in the
form of minute particles, visible only with the microscope, we speak of
the disease as ulceration, not sloughing or mortification. The two pro-
cesses are, however, often mingled, and can be only in general terms,
and in well-marked examples, distinguished.
It might, also, be difficult to define, in precise terms, this death of
parts from some examples of their degeneration. We may doubt, some-
times, whether the degenerative changes, imitated, as certain of them
are, by chemical changes in the tissues after death, are not consequences
of the total cessation of the influence of vital forces ; and it seems nearly
certain that degeneration of a part may proceed to its death, and is
Very apt to do so when, during its progress, many of the conditions of
Untrition are at once interfered with. In a general view we may dis-
tinguish the degeneration of a part from its death by this, — that the
degenerate part never becomes putrid, and that no process ensues for its
separation or isolation, such as we can see in the case of a dead part.
However degenerate a tissue may be, it either remains in continuity
with those around it, or is absorbed. If the same tissue were dead,
those around it would separate from it, and it would be ejected from
them.
Still, it may not be pretended that degeneration and death are sepa-
rated by a strong border-line. Rather, many of the instances of mor-
tification to which I am about to refer may be read as histories of the
transition from one of these conditions to the others It will appear
that a part may degenerate even to death while the rest of the body
remains alive ; that, as a certain diminution of the supply of arterial
blood may lead to degeneration, so a greater diminution may lead to
death ; that, as a certain amount of inflammation has always in it a
0 CAUSES OP MORTIFICATlUxi.
ifective nutrition of the inflamed part, so, in a greater amount, the
aath of the same part ensues ; and that the same agent may kill one
ortion of a tissue and inflame the portions around it. Of all such
;ases we might say that the local death is the extreme of degeneration.
A convenient method of studying the causes of mortification may be
to divide those among them that are explicable into the direct and the
indirect ; t. e. into such as disorganize and kill the tissues at once, and
directly, though sometimes slowly, and such as do so indirectly, by de-
priving them of some or all of the conditions of their nutrition. Such
a division, however, must not lead us to forget that, in many cases, mor-
tification is the result of many concurring causes of both kinds.
I. In the first class we may reckon the mortifications that are the
extremes of degeneration. But these can rarely be observed in un-
mixed examples. The more evident instances are those which result
from great heat, rapidly decomposing chemical agents, and severe me-
chanical injury. The appearances of the dead tissues are, in these
cases, modified by the presence of blood in those that are vascular, and
by the blood being killed in and with them : but the state of the blood
is no cause of their death; the tissues and the contained blood are killed
together ; and the same mode and consequences of mortification would
be manifested in the non-vascular tissues.
Now, as I just suggested, it may be observed of all these destructive
agents, that when they are applied in smaller measure, the effect of the
injury is not to kill the part at once, but to excite an inflammation in
it ; and the inflammatory dcgeqeration, thus added to the damage the
part sustained from the direct effect of the injury, may lead to an indi-
rect or secondary mortification. To this mixed origin, probably, many
of the cases of traumatic gangrene may be ascribed, which are not
manifest very speedily after the injury ; in these we may say that a
severe injury has so nearly disorganized a part, that the subsequent in-
flammation, with the concurrent defective nutrition, has completed its
death. But, mechanical violence, heat, or chemical action, may kill a
tissue at once, without the intervention of inflammation, and although,
in the case of the vascular tissues, it is scarcely possible to separate the
influence of the injury on their proper elements, from that which is, at
the same time, inflicted on their blood and vessels, yet we must consider
the phenomena of mortification as having their scat, essentially, in the
elements of the tissues. Whatever we understand as the life of a part,
that life may cease ; and as the life of a part is its own property, main-
tained, indeed, by the blood and other conditions of nutrition, yet not
derived from them, so may that life cease, or, as it is said, be destroyed,
without interference of the blood or any other exterior conditions of
nutrition.
The immediateness of such death of a part is shown by the rapidity
with which it is manifested. It is nearly instantaneous on the applica-
i
CAUSES OP MORTIFICATION. 811
tion of extreme heat or the strongest mechanical agents ; slower after
mechanical injury : hut within twelve hours of the infliction of a blow
the struck or crushed part may be evidently dead ; there may be little
or no ecchymosis, no sign of inflammation, no pain, except that which
directly followed the injury, and, in the case of a bone, no apparent
change of texture; but the piece of tissue is killed in the midst of the
living parts; its recovery, by the re-establishment of its relations with
the blood, is not possible : it cannot even be absorbed.
II. Among the instances of indirect mortification of parts, the most
numerous are those in which nutrition is made impossible by some defect
either (1) in the quantity, or (2), in the movement, of the blood.
Defects in the quantity of blood have been already noticed as leading
to death of parts (p. 46). The following are the chief general methods
of the events :
The main artery of a part may be closed by pressure, or by some in-
ternal obstruction. Thus, sometimes, sloughing of the foot, or leg, fol-
lows ligature of the femoral artery for popliteal aneurism ; or slough-
ing of part of the brain may follow ligature of the common carotid
artery ; and in this case the difierence, and yet the close relation, be-
tween the death of a part and its degeneration, are well shown (com-
pare p. 46 and 108). Thus, also, through equal internal obstruction of
main arteries, sloughing may follow blows which crack the internal and
middle coats, and let them fold inwards across the stream of blood :*
or, the blocking of masses of fibrine, washed from the left valves of the
heart, and arrested in the iliac or some other artery :f or the closure of
inflamed arteries.
Portions of tissue may similarly perish when, by injury, or by pro-
^essive ulceration or absorption, all their minute bloodvessels are de-
stroyed, and their supply of blood cut ofi". Thus necrosis may follow
the separation of periosteum from the surface of a bone ; when it is
either violently stripped off, or raised by effused blood, or by suppura-
t;ion beneath it. Thus, also, sometimes, as an abscess approaches the
Surface, the thinned skin dies ; and, not like an inflamed part, but as
One deprived of nutriment, it shrivels and is dried. Such sloughing is
^xiore common in perforating ulcers of the stomach or intestines ; in the
Oourse of which, when ulceration has destroyed a portion of the subperi-
toneal tissue and its bloodvessels, the peritoneum, hitherto fed by them,
perishes, and is separated as a grayish or yellowish-white slough. In
like manner, ulceration, in its progress, may so undermine or intrench
a pari, that at length it dies through defect of blood : thus, often, small
fragments of bone are detached in strumous disease of the tarsus and
other parts. And, similarly, through mere defect of blood, the centre
of a tumor may slough: and here, again, is manifest the relation
* Two such specimens are in the Museum of St Bartholomew's.
f Slee Dr. Kirkes's essay in Med.-Chir. Trans., vol. xxxv.
312 GiiUSES OF MORTIFICATION.
between the death, and the more frequent degeneration, of an imper-
fectly nourished part.
The effect of pressure constantly maintained on a part may be a simi-
larly produced mortification: the part may die because its blood is
pressed from it and not renewed; but more commonly, as we see in bed-
sores, inflammation ensues, and the death of the part has a doable or
mixed origin.
Senile gangrene, also, is without doubt, in many cases, due, in a
measure, to defective quantity of blood; but it is a more complicated
example of mortification than any of the foregoing, and I shall there-
fore again refer to it.
I have said that parts may die through defective movement of blood.
It may be present in sufScient or excessive quantity ; but it may be
fatally stagnant. So far as the proper elements of the tissue are con-
cerned, there may be little difference in their modes of death, or in their
subsequent changes, in these two sets of cases ; but, as seen in the mass,
the tissue dead through defect of blood is very different from that dead
through stagnation of blood. In the former, we find little more than
its own structures dried and shrunken or disorganized ; in the latter,
the materials of abundant blood, and often of substances exuded from
the congested vessels, lie mingled with the proper structures, having
died with them. Hence, mainly, the differences between the mortifica-
tions distinguished as the dry and moist gangrenes ; or as the cold and
hot, the white and the black, gangrenes ; these being, respectively, the
technical terms for parts dead through defect, or through stagnation,
of blood.
This stagnation of blood may ensue in many ways. The simplest is
when a part is strangulated ; as the contents of a hernial sac may be.
If the strangulation is sudden and complete, the stagnation is equally
so, and the death of the part follows very quickly, with little excess of
blood in it. But, if the strangulation be less in degree, or be more
slowly completed, the veins suffer more in the gradual compression than
the arteries do ; the vessels of the part thus become gorged with blood,
admitted into them in larger quantity than it can leave them, and so
mortification ensues after intense congestion or inflammation of all the
tissues.*
Mere passive congestion of the vessels of a part may, in enfeebled
persons, lead to mortification : but this is a rare event, for unless a
part be injured, or of itself already degenerate, it may be maintained
by a very slow movement of the blood.
The congestion which more commonly leads to mortification is that
which forms part of the inflammatory process. It is, perhaps, to be
regretted that the cases of this class should have been taken as if they
* This difference in the effects of constrictions of parts is particularly described by Sir &
C. Brodie : Lectures on Surgery and Pathology, p. 304.
CAUSES OP MORTIFICATION. 813
were the simplest types of the process of mortification, and that the
process should have been studied as an appendage, a so-called termina-
tion, of inflammation : for, in truth, the death of an inflamed part is a
very complex matter ; and, in certain examples of it, all the more simple
causes of mortification may be involved. Thus (1) the inflammatory
congestion may end in stagnation of the blood, and this, as an indirect
cause of mortification, may lead to the death of the blood, and that of
the tissues that need moving blood for their support. But (2) a dege-
neration of the proper textures is a constant part of the inflammatory
process ; and this degeneration may itself proceed to death, while it is
concurrent with defects in the conditions of nutrition. And (8) the
exudation of fluid in some inflamed parts may so compress, and by the
swelling so elongate, the bloodvessels, as to diminish materially the
influx of fresh blood, even when little of that already in the part is
stagnant.
All these, and perhaps other, conditions may concur in the mortifica-
tion of an inflamed part ; and their united force is commonly the more
effective, by being exercised in a previously defective or degenerate
condition of the inflamed tissue. The second of them, I think, has
been too little considered ; for by it, more than by any other event, we
may understand the sloughing that ensues in the inflamed parts of
enfeebled persons. The intensity of an inflammation is not, alone, a
measure of the probability of mortification ensuing in its course;
neither is mere debility ; for we daily see inflammation without death
of parts in the feeblest patients with phthisis and other diseases : rather,
when mortification happens in an inflamed part, it seems to be through
the occurrence of the disease in those that have degenerate tissues
because of old age, or defective food or other materials for life, or
through habitual intemperance. It is as if the death of the part wero
the consequence of the defective nutrition, which concurs with the rest
of the inflammatory process, being superadded to that previously exist-
ing in the part. To the same occurrence we may, in some measure,
ascribe the mortification of parts after comparatively slight injuries in
the aged and intemperate : already degenerate, they perish, through
the addition of what, in healthier persons, would have led to only some
degeneration, or to the inflammatory process, in the injured part. Such
cases as these, also, stand in no distant relation to those of the morti-
fication that ensues in inflammations after injuries. And with these we
i»»y probably class the similar effects of intense cold. Cold alone does
Jiot, in general, directly kill a part, whether in cold or in warm-blooded
animals: the death that ensues appears to be the result of inflammation
in the part that was cold or frozen.
Such may be the explanations of the local death that may occur in
inflammation ; but, in many more cases of what appear as mortifications
in inflamed parts, the death is the first event in the process, and the
inflammation appears as its consequence ; or else the death and the in-
21
314 CAUSES OF MORTIFICATION.
flammation are coincident in different parts of the same tissue. To
these cases I shall again refer.
In senile gangrene we commonly find a very large number of condi-
tions ministering to the death of the affected part. First, occurring,
as its name implies, in the old, and often' in those that are old in struc-
ture rather than in years, it affects tissues already degenerate, and at
the very extremity and most feebly nourished part of the body. I
think that, in some cases, its beginning may be when the progressive
degeneration of the part has arrived at death. But, if this do not
happen, some injury or disease, even a very trivial one, kills that which
was already nearly dead; as a severe injury might kill any part, how-
ever actively alive. Now, when death has thus commenced, it may in
the same manner extend more widely and deeply, with little or no sign
of attendant disease ; the parts may successively die, blacken, and be-
come dry and shrivelled ; in this case, the senile gangrene is a dry one.
But more commonly, when a portion of a toe or of the foot has thus
died, the parts around or within it become inflamed, and in these, dege-
nerate as they were already, the further degeneration of the inflamma-
tory process is destructive ; and thus, or in this extent, by progressive
inflammation and death, the gangrene, moist though senile, spreads. In
either case the extension of the gangrene is favored by many other
things; especially by the defective muscular and elastic power, and by
the narrowing or obstruction of the degenerate arteries of the part ; by
the defective movement of the blood, readily inducing a passive con-
gestion or stagnation in parts of its course; by an enfeebled heart; by
the blood being, like the tissues, old, and doubtless, like them, defective ;
and by the aptness of the slow-moving blood to coagulate in the vessels.
All these favor the occurrence and extension of the senile gangrene :
one or more of them may, sometimes, be the efficient cause of it : but
my impression is that it is essentially, and in the first instance, due,
either to senile degeneration having reached its end in local death, or
to the fatal superaddition of an inflammatory degeneration in a part
already scarcely living.
III. In the foregoing cases, we seem able, in some measure, to ex-
plain the occurrence of mortification. But there are yet many cases
m which explanation, except in the most general and vague terms, is
far more difficult. In some, the local death is to be ascribed to defec-
tive quality of the blood, or to morbid materials in it. Among these,
the instances of sloughing of the cornea observed in animals, and more
rarely in men, whose food is deficient in nitrogen ; and those of morti-
fications of the extremities that have ensued after eating rye with ergot,
may prove the general principle, — that certain parts, even small and
circumscribed parts, may die through defects or errors of the blood
which yet do not quite hinder its maintaining the rest of the body.
They may, thus, be types of a large class of cases, in all of which the
death of a portion of tissue seems to ensue through some wrong in the
CAUSES OF MORTIFICATION. 315
blood by whicb their mutual influence is destroyed ; of which cases,
therefore, we may say that as there are morbid conditions of the whole
blood in which local inflammations may have their origin, so are there
others in which local deaths have theirs.
Boils and carbuncles, for example, are of this kind. The sloughs, so
often separated from them, are pale and bloodless ; they are not por-
tions of tissues that have died in consequence of stagnation of blood in
them : they are white sloughs in the midst of inflamed parts. In boils,
the first event of the disease may appear in the small central slough ;
in such cases the surrounding inflammation may appear to be the con-
sequence of the slough ; but, much more probably, it is the result of a
lesser influence of the same morbid condition of the blood. In the idio-
pathic sloughing of the subcutaneous tissue of the scrotum, the local
death is evidently, in some cases, the first event of the disease. To
this class, also, of mortifications in consequence of morbid conditions of
the blood, we must refer, I presume, the cases of hospital gangrene ;
those of the most severe and most rapidly extending traumatic kind ;
those of the sloughings of mucous membranes, and other parts, that ,
sometimes ensue in typhus, scarlet fever, and other allied diseases,
when they deviate from their ordinary course ; the sloughing of syphi-
litic sores, and many others.
Lastly, we may enumerate among the causes of death of parts the
defect of nervous force : but the examples of this have been related in
a former lecture (p. 51) ;* and it only needs, perhaps, to be said here
that this defect may mingle its influence wjth many other obvious causes
of mortification. When a part is severely injured, its nerves suffer pro-
portionate violence, and their defective force may add to the danger of
mortification ; in the old, not the blood, or the tissues alone, are de-
generate, but the nervous structures also ; and defective nervous force
may be, in them, counted among the many conditions favorable to the
senile gangrene ; and so, yet more evidently, the sloughing of com-
pressed parts is peculiarly rapid and severe when those parts are de-
prived of nervous force by injury of the spinal cord, or otherwise.
While the causes of mortification arp so manifold ; while it is, in fact,
the end of so many different affections, it is not strange that the appear-
ances of the dying and dead parts should be extremely various. The
changes in them (independent of those produced by great heat, caustics,
or other such disorganizing agents) may be referred to three chief
sources : namely, (1) those that ensue in the dying and dead tissues ;
(2) those in the blood, dying with the tissues and often accumulated in
them in unnatural abundance ; (3) those which are due to the inflamma-
tion or other disease or injury, which has preceded the death of the
* There are yet many cases which I can neither explain nor classify ; such as those from
the effects of animal poisons, malignant pustule, peculiar gangrenes of the skin, and many
others. On all these, and, indeed, on the whole subject of mortifications, the reader will
find DO work that he can study with so much profit as the lectures of Sir B. C. Brodie.
816 CHARACTERS OP MORTIFICATION.
part, and of which the products die with the tissue and the blood, and
change with them after death.
But, though we may thus classify the morbid changes in mortified
parts, yet we can hardly enumerate the varieties which, in each class,
are due to the previous diseases of the part, or to external conditions ;
such as differences of temperature, of moisture, and others. All the
chemical changes which, in life, are repaired and unobserved, are here
cumulative ; all those external forces are now submitted to, which, while
the parts were living, they seemed to disregard ; so exactly were they
adjusted in counteraction. It is, therefore, only in typical examples
that mortifications can be well described. The technical terms applied
to them have been already mentioned ; and "dryland " moist" signify
the chief differences dependent on the quantity of blood and of inflam-
matory products in the dead parts. " Dry gangrene' ' is usually preceded
by diminished supply of blood to the part ; *' moist or humid gangrene"
by increased supply, and often by inflammation ; the former more slowly
progressive is usually a "chronic," or, as some have called it, "cold
gangrene;" the latter an "acute or hot gangrene."
Among the examples of mortification due to defective supply of blood,
and therefore classed as dry gangrenes, great differences of appearance
are due to the degrees in which the dead parts can be dried. As it
may be observed in the integuments of the leg, for example, it may be
noticed that, in the first instance, the part about to die appears livid, or
mottled with various dusky shades of purple, brown, or indigo, through
which it seems to pass as its colors change from the dull ruddiness of
stagnant or tardy blood towards the blackness of complete death. It
becomes colder, and gradually insensible ; its cuticle separates, and is
raised in blisters by a serous, or more or less blood-colored, or brown-
ish fluid. Then, as the cuticle breaks and is removed, the subjacent
integument, hitherto kept moist, being now exposed to the air, gradually
becomes drier ; withering, mummifying, becoming dark brown and black,
having a mouldy rather than a putrid smell ; it is changed, as Roki-
tansky says,* like organic substances decomposed with insufficient mois-
ture and with separation of free carbon. Such are the changes often
seen in the dry senile gangrene, and in that which may follow obstruc-
tion of the main arteries in young persons : but, very generally, as the
interior parts of the limb cannot be dried so quickly as the exterior, and
are, perhaps, less completely deprived of their supply of blood, they, or
portions of them, become soft and putrid, while the integuments become
dry and musty.
In other cases of mortification similarly caused, the dead parts, though
deprived of blood, cannot become dry ; either they are not exposed to
air, or they are soaked with fluid exuded near them. In these instances
the sloughs may be dark ; but they are commonly nearly white ; and
* Pathologische Anatomic, i, p. 237.
CHARACTERS OP MORTIFICATION. 317
bence one of the grounds for the technical distinction of white and
black gangrene. Such white sloughs are commonly seen when the
peritoneum mortifies, after being deprived of blood by ulceration gradu-
ally deepening in the walls of the digestive canal ; and, sometimes, in
the integuments over an abscess, when the cuticle has not previously
separated. If this have happened, the dead and undermined integu-
ment may become dry and horny; but if the cuticle remain, it is com-
monly white, soft, and putrid.
The typical examples of the moist gangrene are those which occur
in inflamed parts, and chiefly in consequence of inflammation, and to
which, therefore, the names of " acute'* and " hot" gangrene have been
applied. We must not reckon among these the cases in which the death
of the part precedes, or has a common origin with, the inflammation ;
for in these, as in boils, carbuncles, and hospital gangrene, the slough
is commonly bloodless, white or yellowish, or grayish-white, and, if it
were not immersed in fluid, would probably be dry and shrivelled. The
mortification that occurs during inflammation, and as in part a conse-
quence of it, finds the tissues full of blood, and often of exuded lymph
and serum, which all perish with them.
If such a process be watched in an inflammation involving the integu-
ments, or in senile gangrene rapidly progressive with inflammation, or,
as in the most striking instance, in the traumatic gangrene following a
severe injury of a limb, the parts that were swollen, full red, and hot,
and perhaps very tense and painful, become mottled with overspread-
ing shades of dusky brown, green, blue, and black. "These tints, in
mortification after injuries, may, sometimes, seem at first like the effects
of ecchymoses ; and often, after fractures of the leg, a further likeness
between the two is produced by the rising of the cuticle in blisters filled
with serous or blood-colored fluids at the most injured parts. But the
coincident or quickly following signs of mortification leave no doubt of
what is happening. The discolored parts become cold and insensible,
and more and more dark, except at their borders, which are dusky red ;
a thin, brownish, stinking fluid, issues from the exposed integuments ;
gas is evolved from similar fluids decomposing in the deeper-seated tis-
sues, and its bubbles crepitate as we press them ; the limb retains its
size or enlarges, but its tissues are no longer tense ; they soften as in
inflammation, but both more rapidly and more thoroughly, for they be-
come utterly rotten. At the borders of the dying and dead tissues, if
the mortification be still extending, these changes are gradually lost ;
the colors fade into the dusky red of the inflamed but still living parts ;
and the tint of these parts may affbrd the earliest and best sign of the
progress towards death, or the return to a more perfect life. Their be-
coming more dark and dull, with a browner red, is the sure precursor
of their death ; their brightening and assuming a more florid hue, is as
sure a sign, that they are more actively alive. Doubtless the varieties
of color indicate, respectively, the stagnation and the movement of the
818 0HARACTBR8 OF MORTIFICATION.
blood in the parts which, thus situated, may, according to the progress
of their inflammation, be added to the dead, or become the apparatus of
repair.*
The interior of a part thus mortified corresponds with the foregoing
description. All the softer tissues are, like the integuments, rotten,
soft, putrid, soaked with serum, and decomposed exuded fluid; ash-
colored, green or brown ; more rarely blue or black ; crackling with
various gases extricated in decomposition. The tendons and articular
cartilages in a mortified limb may seem but little changed ; at the most
they may be softened, and deprived of lustre. The bones appear dry,
bloodless, and often like such as have b^en macerated and bleached ;
their periosteum is usually separated from them, or may be easily and
cleanly stripped off. But these harder and interior parts of a limb
either die more slowly, or more slowly manifest the signs of death, than
do those around them ; for not only do they appear comparatively little
changed, but often when all the dead soft parts are completely sepa-
rated from the living, the bone remains continuous, and its medullary
vessels bleed when it is sawn off. Usually, also, after complete spon-
taneous separation of the mortified part of a limb, the stump is conical ;
the outer parts of it having died higher up than the parts in its axis.
Another appearance of mortified parts, characteristic of a class, is
presented after they have been strangulated. I have mentioned the
difference which in these cases depends on whether the strangulation
have been sudde^ly complete, or have been gradually made perfect.
In the former case the slough is very quickly formed, and may be ash-
colored, gray, or whitish, and apt to shrivel and become dry before iU
separation. In the latter case, as best exemplified in strangulated
hernia, the bloodvessels become gradually more and more full, and the
blood more dark, till the walls of the intestine, passing through the
deepest tints of blood-color and of crimson, become completely black.
Commonly, by partial extravasation of blood, and by inflammatory
exudation, they become also thick, firm, and leathery, a condition
which materially adds to the diflSculty of reducing the hernia, but
which is generally an evidence that the tissues are not dead ; for when
they are dead, they become not only duller to the eye, but softer,
more flaccid and yielding, and easily torn, like the rotten tissues of
other mortified parts. The canal, which was before cylindrical, may
now collapse ; and now, commonly, the odor of the intestinal contents
penetrates its walls.
I have spoken of the death of the blood as coinciding with that of the
part in whose vessels it is inclosed. Very commonly, when this happens,
coagulation of blood ensues in the vessels for some distance above, i. e.,
* Among the products of decomposition on the surfaces of wounds, are little filaments
and flocculi of soft orange, or brownish yellow substance, often seen, but particularly de-
scribed first by Zeis (M6moires de la Soc. de Biologic. Ann6e 1855). They are shreds of
connective tissue (generally) mingled with fatty and molecular matter, which may be co-
lored, and with crystals of cholesterine.
SEPARATION OF MORTIFIED PARTS. 819
nearer to the heart than the mortified parts. Hence, as it has heen
often observed, no bleeding may occur from even large arteries divided
in amputations above the dead parts of sloughing limbs.
It remains now to speak of the phenomena which ensue when gan-
grene ceases, and of which the end is, that the dead parts are separated
from the living.
As for the dead parts, they only continue to decompo3e, while, if
exposed to a dry atmosphere, they gradually shrivel, becoming drier
and darker. But more important changes ensue in the living parts
that border them. The first change that occurs in this process (the
whole of which may be studied as the most remarkable instance of the
adaptation of disease for the recovery of health), the first indication of
the coming reparative process, is a more decided limitation and contrast
of color at the border of the dying part. As we watch it in the in-
teguments, the dusky redness of the surrounding skin becomes more
bright, and paler, as if mingled with pink rather than with brown; and
the contrast reaches its height when, as the redness of the living part
brightens, the dead whiteness or blackness of the slough becomes more
perfect. The touch may detect a corresponding contrast : the living
part, turgid with moving blood, feels tense and warm ; the dead part is
soft, or inelastic, cold, and often a little sunken below the level of the
living. These contrasts mark out the limits of the two parts : they
constitute the 'Mine of demarcation" between them.
The separation of the dead and living parts, which remain continuous
for various periods after the mortification has ceased, and the line of
demarcation is formed, is accomplished by the ulceration of the portions
of the living tissues which are immediately contiguous to the dead. At
this border, and (in parts that are exposed) commencing at the surface,
a groove is formed by ulceration, which circumscribes and intrenches
the dead part, and then, gradually deepening and converging, under-
mines it, till, reaching its centre, the separation is completed, and the
slough falls or is dislodged by the discharge from the surface of the
ulcerated living part. Commonly, before the border of the integuments
ulcerates, it becomes white and very soft, so that, for a time, a dull
white line appears to divide the dead and living parts.
Closely following in the wake of this process of ulceration is one
more definitely directed towards repair. As the ulcerated groove
deepens day by day around and beneath the dead part, so do granula-
tion-cells rise from its surface ; so that, as one might say, that which
was yesterday ulcerating, is to- day granulating; and thus very soon
after the slough is separated, the whole surface of the living part, from
which it was detached, is covered with granulations, and proceeds, like
an ordinary ulcer, towards healing.
There is, I believe, nothing in the method of thus separating a dead
part, thus ^^ casting ofi*a slough,'* which is not in conformity with the
320 SEPARATION OF MORTIFIED PARTS.
general process of ulceration. When a portion of the very interior
substance of an organ dies, and is separated, there may be doubt, as in
some nearly corresponding cases of ulceration, whether the clearing
away of the living tissue adjacent to it be effected by absorption or by
disintegration, and mingling with the fluid in which, after separation,
the dead piece lies. We may have this doubt in such cases as the
sloughing of subcutaneous tissue in carbuncles not yet open, or in phleg-
monous erysipelas, or in cases of internal necrosis ; in which, without
any external discharge, pieces of dead tissue are completely detached
from the living tissue around them : and I do not know how such doubt
can be solved. But the separation of superficial or exposed dead parts
might be studied as the type of the ulcerative process, of which, indeed,
it is in disease the usual beginning, and with the more advantage, be-
cause the sloughing of parts of limbs affords illustrations of the process
in tissues in which it very rarely happens otherwise. Especially, it
shows the times at which, in different tissues, ulceration may ensue,
and hereby the times during which, under similar conditions of hindered
nutrition, the tissues may severally maintain life.
The process which I have exemplified by the mortification of soft
parts has an exact and instructive parallel in necrosis or mortification
of bone ; but there are in the phenomena of necrosis some things which
deserve a brief mention, because of their clearly illustrating the general
nature of the process following the death of a part.
Thus (1) we find in bones a permanent evidence of the increase of
vascularity of the tissues around a dead part; for, in specimens of ne-
crosis, the bone at the border of the dead piece has always very nu-
merous and enlarged Haversian canals.* (2) We may often see that
the reparative process, on the borders of the living part, keeps pace
with, or rather precedes by some short interval, the process by which
the living and the dead are separated : for new bone is always formed
in and beneath the periosteum at the border of the living bone, while
the groove around the dead piece is being deepened, or even before its
formation has commenced. (3) Instances of necrosis show some of the
progressive changes that lead to the formation of the groove of separa-
tion. The bone at the very junction of the living and the dead becomes,
first, soft and ruddy, as an inflamed bone does. Its earthy matter, as
Mr. Hunter described, is first (by absorption, as we must suppose) re-
moved in larger proportion than its animal basis. This basis remains,
for a time, connecting the dead and the living bone, both of which
retaining their natural hardness, appear in strong contrast with it ; but
soon this also is removed, and the separation is completed. (4) From
* In these enlarged canals, as well as in the lacunae, which also undergo increase in
size, an abundant growth of cells, which fill their cavities, takes place. By the formation
of pus from these cells, the dead bone is separated, or, as it were, iSoated off. J. Goodsir,
op. cit. : Virchow, Cell. Pathologic.
SPECIFIC DISEASES. 821
some cases of necrosis, also, we obtain evidence on 41 question about
the removal of dead tissue. It is asked whether dead tissue may not
be absorbed, and so removed. Examples of necrosis show that, in the
large majority of cases, the separation of dead bone is accomplished
entirely by the ulceration or absorption of the living bone around it ;
but that, in certain cases, especially in those in which pieces of bone,
though dead, remain continuous with the living, the dead bone may be
in part absorbed, or otherwise removed, not indeed in mass, but after
being disintegrated or dissolved.* (5) In cases of necrosis we find the
best examples in which, apparently through want of vital force, the
dead and living parts remain long united and continuous. A piece of
dead bone, proved to be dead by its blackness, insensibility, and total
absence of change, may remain even for months connected with living
bone : and no process for its separation is established, till the patient's
general health improves. (6) Lastly, in the death of bone, we may see
a simpler process for the separation of the living tissues than that which
18 accomplished by ulceration. In superficial necrosis, the periosteum,
at least in those parts in which its own tissue does not penetrate, so as
to be continuous with, that of the bone, separates cleanly from the sur-
face of the dead bone, retaining its own integrity and smoothness, and
leaving the bone equally entire and smooth. No observations have yet
been made, I believe, which show how this retirement of one tissue
from another is effected, or how the bloodvessels that pass from one to
the other are disposed of. Another method of separation without the
ulcerative process is observed when teeth die, especially in old persons.
Their sockets enlarge, apparently by mere atrophy or absorption of
their walls and margins ; so that the teeth-fangs are no longer tightly
^'■^fiped by them, but become loose, and project further from the jaw.
LECTURE XX.
SPECIFIC DISEASES.
It would be far beyond the design of these lectures, intended only
w the illustration of the General Principles of Pathology, in its rela-
^^ns with Surgery, if I were to enter largely on the consideration of
Such cases are recorded by Mr. Stanley, in whose Treatise on Diseases of the Bones I
'^ hardly say that all the phenomena of necrosis are much more fully described than they
*^ here. The possibility of the absorption of dead bone seems amply proved by cases
(one of which I watched while it was under his care) in which portions of pegs of ivory,
driven like nails into bones, to excite inflammation for the repair of ununited fractures, have
been removed. The absorption, I say, seems amply proved ; but the method of it is made,
^th.9 same observation^ more difficult than ever to explain ; for only those portions of the
ivory that were imbedded in the bone were absorbed ; the portions that were not in contact
witii bone, tboagb imbedded in granulations or pus, were unchanged.
322 DISTINCTIONS BETWEEN COMMON
the diseases named specific. It will be sufficient, I hope, and certainly
will more nearly correspond with the rest of my plan, if I describe the
general features of specific diseases, and their general import ; and if I
point out, though only in suggestions, how we may more efiectually
study them ; how many things relating to them, which we are apt to
disiniss with words, may be subjects of deeper, and perhaps useful,
thought.
The term "specific disease," as employed in common usage and in
its most general sense, means something distinct from common or simple
disease. Thus, when a "specific inflammation," or a "specific ulcer,"
is spoken of, we understand that these present certain features in which
they difier from what the same person would call " a common," or a
"simple inflammation," or "ulcer." The specific characters of any
disease, whether syphilis or hydrophobia, gout or rheumatism, typhus,
small-pox, or any other, are those in which it constantly deviates from
the characters of a common or simple disease of the same general kind.*
Our first inquiry, therefore, must be,— what are these common diseases,
which we seem to be agreed to take as the standard by which to measure
the specific characters of others ?
I believe that, in relation to inflammatory diseases and their con-
sequences, our chief thoughts concerning such standards for compari-
son are derived from the affections which follow injuries by violence, or
by inorganic chemical agents, by heat, or any other commonly applied
causes of disease. When such a blow is inflicted as kills a portion of
the body, its consequences afford a standard with which we may com-
pare all other instances of mortification and sloughing; and when,
among these, we find a certain number of examples which differ, in
some constant characters, from this standard, we place them, as it
were, in a separate group, as examples of a specific disease. Or, again,
when a part is submitted to such pressure as leads to its ulceration, we
regard the disease as a common, simple, or standard ulcer ; and by
their several constant differences from it, and from one another, we
judge of the various ulcers which we name specific. In like manner,
our standard of common or simple inflammation seems to be derived
from the processes which follow violence ; the application of heat, the
lodgement of foreign bodies, or the application of certain chemical
stimulants. And the standard of common or simple fever is that which
ensues in a previously healthy man, soon after he has received some
such local injury as any of these agents might produce. Now, it is
* It may not be unnecessary to guard some students at once from the suspicion, which
the terms in common use may suggest, that there is a correspondence between the species
of diseases and those of living creatures as studied in natural history. There is really no
likeness, correspondence, or true analogy between them ; and if nosological systems, framed
after the pattern of those of zoology, lead to the belief that they have any other resemblance
than that of the modes of briefly describing, and of grouping double names, they had better
be disused.
AND SPECIFIC DISEASES. 323
very reasonable that we should take these as the best examples of com-
mon or simple disease ; the best, I mean, for comparison with those
that may be called specific. For not only can we produce some of
these common diseases when we will, and study them experimentally,
but they manifestly present disease in its least complicated form ; least
specified by peculiarities either in its cause or in its subject. Only, in
adjusting our standards of disease from them, it is necessary that we
should take the character presented by all or by the great majority of
instances; since the consequences of even the simplest mechanical in-
juries are apt to vary according to the peculiar constitution of the
person injured.
The terms simple and specific are sometimes applied, in equal con-
tradistinction, to tumors. Here we have no such standard of accidental
or experimental disease ; but that which seems to be taken as the
measure of simplicity in a tumor, is the conformity of jts structure with
some of the natural parts of the body. The more a tumor is like a
mere overgrowth of some natural structure, the more "simple" is it
considered ; and the specific characters of a tumor are chiefly those in
which, whether in texture or in mode of life, it differs from the natural
parts. When, however, a tumor is diseased, — for instance, when a
cancer ulcerates, — the specific characters of the ulcer are estimated by
comparison with the characters of common or simple ulcers.
Such are, in the most general terms, the standards of common or
simple diseases. The title " common'* applied to them is, in another
flense, justified by the features which they present being, for the most
part, common to them and to' the specific diseases. For, in the specific
diseases, we do not find morbid processes altogether different from those
irhich are taken as standards, but only such processes as are conformed
with them in all general and common features, but differ from them by
some modification or addition. In other words, no specific disease is
entirely peculiar or specific ; each consists of a common morbid process,
'Whether an inflammation, an ulceration, a gangrene, or any other, and
of a specific modification' or plan in some part thereof.
Let us now see what these modifications, these specific characters,
^re ; and here, the history of tumors being for the present postponed,
let me almost limit the inquiry to a comparison of the inflammatory
affections of the two kinds, and select examples frooi only such as are,
by the most general consent, called specific ; as syphilis, gout, rheuma-
tism, the eruptive fevers, and the like.
1. Each specific disease constantly observes a certain plan or con-
stnjction in its morbid process ; each, as I just said, presents the phe-
nomena of a common or simple disease, but either there is some addition
to these, or, else, one or more of these are so modified as to constitute
a specific character; a peculiarity by which each is distinguished at once
from all common, and from all other specific diseases. Thus, we see a
324 DISTINCTIONS BETWEEN COMMON
patient with, say, two or three annular or crescentic ulcers on his legs ;
and, if we can watch these, they are, perhaps, healing at their concave
borders at the same time as they are extending at their convex borders.
Now, here are all the conditions that belong to common ulcers ; and, in
different instances, we might find these ulcers liable to the variations of
common ones, as being more or less inflamed or congested, acute or
chronic, progressive or stationary ; but we look beyond these characters,
and see, in the shape and mode of extension of these ulcers, properties
which are not observed in common ones; we recognize these as specific
characters ; we may call the ulcers specific ; or, because we know how
commonly such ulcers occur in syphilis, and how rarely in any other
disease, we call them syphilitic ulcers, and treat them with iodide of
potassium, or some other specific ; that is, specially curative medicines.
Another patient has, say, numerous small, round, duSky, or light brown-
ish-red, slightly elevated patches of inflammation of the surface of his
skin ; on many of them there are small, dry, white scales ; and some of
them may be arranged in a ring. Here, again, are the common charac-
ters of inflammation : but they are peculiarized in plan and tint of red-
ness, and in general aspect ; and because of these we regard the disease
as specific, and call it psoriasis, and, because of the additional peculiarity
of dusky or coppery redness, and of the annular or some other figurative
arrangement, we suspect that it is syphilitic psoriasis. Or, we look
through a series of preparations of ulcerated intestines ; and we call one
ulcer simple or catarrhal, another typhous, another dysenteric, a fourth
tuberculous : all have the common characters of ulcers; but these are,
in each, peculiarly or specifically modified in some respect of plan; and
the modifications are so constant, that without hearing any history of
the specimens, we may be sure of all the chief events of the disease by
which each ulcer was preceded. Or, among a heap of diseased bones,
we can select those whose possessors were strumous, rheumatic, syphi-
litic, or cancerous ; finding in them specific modifications of the results
of some common diseases, such as new bone, i. e. ossified inflammatory
deposits, arranged in peculiar methods of construction, or at particular
parts ; or ulcers of peculiar shape and peculiar method of extension.
I need not cite more examples of the thousand varieties in which the
common phenomena of disease are modified in specific diseases. In
some, the most evident specific characteristics are peculiar affections of
the movement of the blood, as in the cutaneous erythemata ; in some,
affections of certain parts of the nervous centres, as in tetanus, hydro-
phobia, and hooping-cough ; in some, peculiar exudations from the blood,
as in gout, and the inoculable diseases ; in some, peculiar structures
formed by the exuded materials, as in variola, vaccinia, and other cuta-
neous pustular eruptions ; in some, destruction of tissues, as in the ulcers
of syphilis, the sloughs of boils and carbuncles; in some, peculiar
growths, as in cancer ; in some, or indeed in nearly all, peculiar me-
thods of febrile general disturbance ; but, in each of all the number,
AND SPECIFIC DISEASES. 325
the phenomena admit of distinction into those of common disease, and
those in which such disease is peculiarly modified, or by which, if I may
so say, it is specificated.
The morbid process thus modified may be local or general. Usually,
in specific diseases, both local and general morbid processes are concur-
rent, and both are, in a measure, specific; but, although we can scarcely
doubt that there is in every case an exact and specific correspondence
between the two, yet, at present, the general or constitutional affections
of many different specific diseases appear so alike, that we derive our
evidence of specific characters almost entirely from the local part of
the disease. The premonitory general disturbances of the exanthe-
mata, or the slighter disorders preceding cutaneous eruptions, are, seve-
rally, so alike, that, except by collateral evidence, we could seldom do
more than guess what they portend ; their specific modifications of com-
mon general disturbance are too slight for us to recognize them with our
present knowledge and means of observation.
2. Observing the causes of specific diseases, we find that some, and
these the most striking examples of the whole class, are due to the
introduction of peculiar organic compounds, — morbid poisons, as they
are generally called, — into the blood. Such are all the diseases that
can be transmitted by inoculation, contagion, or infection. All these
are essentially specific diseases ; each of them is produced by a distinct
substance, and each produces the same substance, and by a morbid pro-
cess separates it from the blood. In most of these, also, as well as in
many of which the causes are internal and less evident, the local phe-
nomena are preceded by some affection of the whole economy ; the
whole blood seems diseased, and nearly every function and sensation is
more or less disturbed from its health ; the patient feels " ill all over,"
before the local disease appears ; i. e. before the more distinct and
specific morbid process is manifest in the place of inoculation, or in
some other part. Herein is a very general ground of distinction be-
tween the specific and the simple or common diseases : in the latter, the
local phenomena precede the general or constitutional ; in the former,
the order is reversed. We might, indeed, expect this to be a constant
difference between the two ; and perhaps it is so ; for though many
exceptions to any rule founded on it might be adduced, yet these may
be ascribed to the unavoidable sources of fallacy in our observations.
Thus, every severe injury, every long-continued irritation, excites at
once both local and general disease ; and the latter may be evident
before the former, and may not only modify it, but may seem to pro-
dace it. On the other hand, the insertion of certain specific poisons,
e. g. that of the venom of a serpent or an insect, gives rise so rapidly
to specific local disease, that this seems to precede all constitutional
affection.
Notwithstanding such exceptions as these are, or seem to be, this
contrast between specific and common diseases, in regard to the order
826 DISTINCTIONS BBTWRBN COMMON
in whicli the local and constitutional symptoms arise, is so usual that
the terms specific and constitutional are often employed as convertible
terms in relation to disease. But this is not convenient ; for some spe-
cific diseases are, or become, local ; and some constitutional diseases are
not specific.
3. A character very generally observed in specific diseases is an
apparent want of proportion between the cause and the efiect. In
common disease, one might say that, on the whole, the quantity of local
disease is in direct proportion to the cau^e exciting it — whether violent
injury, heat, poifeon, or any other. Numerous exceptions might be
found, but this is, on the whole, the rule.* In specific diseases there
is no appearance of such a rule : we cannot doubt its existence, but it is
lost sight of. Thus, in small-pox, measles, hydrophobia, or syphilis,
the severity of the disease is not, evidently, proportionate to the cause
applied ; a minimum of inoculated virus engenders as vast a disease as
any larger quantity might.
4. I have said that there is generally a correspondence between the
local and the constitutional characters of a specific disease ; but this is
only in respect of quality ; in respect of quantity there is often such a
want of correspondence between the two as we rarely or never see in
common diseases. In general, the amount of common inflammatory
fever after an operation bears a direct proportion to the injury, and the
amount of hectic fever to the quantity of local disease (here, again, are
numerous exceptions, but this is the rule) : but in specific diseases it is
far otherwise. In syphilis and cancer, the severest defects or disturb-
ances in the whole economy may coexist with the smallest amounts of
specific local disease ; and, as Dr. Robert Williamsf has well said, " It
may be laid down as a general law, that when a morbid poison acts with
its greatest intensity, and produces its severest forms of disease, fewer
traces of organic alteration of structure will be found than when the
disorder has been of a milder character.'* *
5. To specific diseases belong all that was said, in former Lectures
(p. 35 e. s.), of the symmetrical diseases, and of seats of election : such
phenomena occur in degenerations, but, I think, in no common diseases.
6. The local process of a specific disease of nutrition is less apt than
that of a common one to be nearly limited to the area in which, in the
first instance, the cause of disease was applied. Specific diseases are
peculiarly prone to spread, that is, to extend their area. They also,
among the diseases of nutrition, are alone capable of being erratic, i. e.
of disappearing from the part in which they were first manifest, while
* I am tempted to say here, that, in patliolopy, we must admit the existence of many
rules or laws the seeming exceptions to which are more numerous than the plain examples
of them. This, however, is notenongh to invalidate the truth of the laws: it could scarcely
be otherwise in the case of laws, tlie exact observance of which requires the concurrenceof
so many conditions as are engaged in nearly all the phenomena studied in pathology.
t Elements of Medicine, vol. i, p. 12.
AND SPECIFIC DISEASES. 827
extending thence through other parts continuous with it ; and they
alone are capable of metiststasis, t. e., of suddenly ceasing in one locality,
and manifesting themselres, with similar local phenomena, in another.
7. In all the particulars mentioned in the last preceding, and in some
of the earlier paragraphs, specific diseases manifest a peculiar character,
in that they seem capable of self-augmentation ; no evident fresh cause
is applied, and yet the disease increases : witness the seemingly spon-
taneous increase of manifest local disease in secondary and tertiary
syphilis, or in the increasing eruption of eczema or of herpes, or the ex-
tension of a carbuncle, or the multiplication of secondary cancers.
8. Specific diseases alone are capable of transformation or metamor-
phosis. As we watch a common disease, its changes seem to be only
those of degree ; it appears increasing or declining, but is always the
same, and a continuous disease. But in many specific diseases we see
changes in quality or kind, as well as in quantity. In syphilis, for ex-
ample, a long series of diseases may occur as the successive conse-
quences of one primary disease different from them all. They are all,
m one sense, the same disease, as having a single origin ; but it is a
disease susceptible of change in so far as it manifests itself at different
times, not only in different parts, but in different forms in each, and in
forms which are not wholly determined by the nature of the tissue
affected. The successive phenomena of measles, scarlet fever, and
many others, may, I think, be similarly expressed as metamorphoses or
transformations of disease.
9. A similar transformation of specific diseases may take place in
their transference from one person to another, whether by inheritance,*
or by infection, or contagion. A parent with one form of secondary
syphilis may have a child with another form ; the child of a parent with
scirrhous cancer may have an epithelial, a colloid, or a medullary can-
cer ; the inoculation of several persons with the matter from one pri-
mary syphilitic sore may produce different forms of the primary disease
and different consecutive phenomena; the same contagion of small-pox,
measles, or scarlet fever, may produce in different subjects all the modi-
fications of which those diseases are severally capable ; the puerperal
woman, or the patient who has sustained a severe accidental or surgical
injury, may modify, or, as it were, color, with the peculiarities of her
own condition, whatever epidemic or other zymotic diseases she may
incur, t
10. Lastly, time is a peculiarly important condition in many of the
specific diseases. If we except the period of calm or incubation, which
Qsually occurs between the infliction of an injury and the beginning of
* It might seem as if none but specific diseases could be hereditary; but many tumors
■re to which we cannot well call specific : such as the cutaneous cysts or wens, and fatty
and cartilagiDous tumors.
f See Carpenter; Br. and For. Med.-Chir. Review, Jan. 1853, quoting from Simpson, in
Monthly Jonm. of Med. So. vol. xi and ziii.
/
328 THEORY OF SPECIFIC DISEASBb.
an evident reparative process, a period of which the length is, in general,
proportionate to the severity of the injury, there are few of the events
of common diseases that are periodic or measurable in time; there are
none that are regularly intermittent or remittent ; none that can be
compared, for regularity, with the set times of latency of the morbid
poisons of the eruptive fevers, or the periods in which they run their
course, or change their plan or chief place of action. Neither are
there, in common diseases, any periods of latency so long as those
which elapse between the application of the specific cause, and the ap-
pearance*of its specific effect, in the eruptive fevers, tetanus, or hydro-
phobia.
Such, briefly, are the chief general characters of the diseases which
are commonly named specific, or described as having something specific
in their action. In some of them, chiefly such as depend on distinct
morbid poisons, whether miasma or virus, or matter of contagion, all
these characters may be observed ; and these are the best types of the
class. In others, part only of the same characters concur. I do not
pretend to define the exact boundary of what should be called specific,
and what common, in diseases ; but it seems reasonable that any disease,
in which the majority of the characters just enumerated are found,
should be studied as one of the class, and that its phenomena should
be interpreted, if possible, by the rules, or by the theory derived from
the more typical members of the same class.
The theory of specific diseases, in its most general terms, is, that
each of them depends on a definite and specific morbid condition of the
blood ; that the local process in which each is manifested is due to the
disorder produced by the morbid blood in the nutrition of one or
more tissues ; and that, generally, this disorder is attended with the ac-
cumulation, and leads to the discharge, or transformation, of some mor-
bid constituents of the blood in the disordered part. It is held, also,
that, in some specific diseases, the morbid condition of the blood con-
sists in undue proportions of one or more of its normal constituents ;
and that, in others, some new morbid substance is added to or formed in
the blood. In either case, the theory is, that the phenomena of each
specific disease depend chiefly, and in the first instance, on certain cor-
responding specific materials in the blood: and that if characteristic
morbid structures be formed in the local process, they are organs in
which these morbid materials are incorporated.
Now, in regard to certain diseases, such as some of those that can be
communicated by inoculation, these terras are scarcely theoretical; they
may rather be taken as the simplest expressions of facts. For exam-
ple (as I have already said, p. 301) in either syphilis, vaccinia, glanders,
or small-pox, especially when produced by inoculation, we have demon-
stration (1) of a morbid condition of the blood ; (2) of the definite anc^
specific nature of that condition, in that it is, and may be at will, pre
THEORY OF SPECIFIC DISEASES. 329
dnced by the introduction of a definite substance into the blood, and
manifests itself in a local disease which, within certain limits, has con-
stant characters ; and (3) of the same substance being accumulated and
discharged, or for a time incorporated in the morbid structures, at the
seat of the local disease. And it seems important to mark, that all
which is thus seen in some specific diseases, and is assumed for the ex-
planation of others, is consistent with facts of physiology ; especially
with those referred to in a former Lecture (p. 40, e. s.), as evidences,
that certain normal organs of the body are formed in consequence of
the presence of materials in the blood, which, in relation to them, might
be called specific, and which they, in their formation, take from the
blood, and incorporate in their own structures.*
The proof of the theory of specific diseases is scarcely less complete
for all those that are infectious or contagious, but cannot be communi-
cated by inoculations — such as typhus, measles, erysipelas ; and scarcely
less for those which are neither infectious nor contagious, but depend,
like cholera and ague, on certain materials which are introduced into
the blood, and produce uniform results, though they are not proved to
exist in the products of the morbid processes. For other diseases,
classed or usually regarded as specific, such as gout, rheumatism, car-
buncle, boil, the various definite, but not communicable, cutaneous
eruptions, hydrophobia, tetanus, and many more, the evidences of the
theory are less complete. Yet they seem not insufficient ; while we
have, in many of these afiections, proofs of the accumulation and sepa-
ration of morbid substances at the seats of local disease, and while, in
all, the chief phenomena are in close conformity with those of the dis-
.eases which are typically specific. Relying on the similarity of all the
members of the group of specific diseases, on the sufficiency of the
terms of the theory for the expression of the facts concerning them
all, and on the evidences more or less complete which each of them sup-
plies for its truth, we seem justified in adopting the same theory for
them all.f
* Abaudant illastrations of the same general laws, of both healthy and morbid formation
of stmctures incorporating specific materials from the blood, are supplied by the action of
medicines whose operation ensues in only certain organs. Dr. Robert Williams (1. c. p. 8)
has jostly said, ** The general laws observable in the actions of morbid poisons are, for the
mon pan, precisely similar to those which govern medicinal substances, or only difier in a
few minor points." The subject is too extensive for discussion here. It is admirably
treated by Mr. Simon in his Lectures on Pathology ; the work, which together with that
of Dr. Robert Williams, may be studied with more profit in relation to all the subjects of
this lecture than any I have yet read.
.f Without going so far as Virchow, who regards every enduring change in the circulating
joioes as derived from fixed points of the body, from single organs or tissues, and who looks
for ** localization for the difi!erent dyscrasiae ;" that is, for definite tissues from out of which
the blood derives its disturbance, yet it may be reasonably granted, that any diseased organ
or tiMoe mnst, through the nutritive changes which take place between it and the blood,
ocMMuitly act as a centre or focus, from which a disturbance afieoting the entire mass of
bknd may ariae.
22
330 HISTOEY OF MORBID MATERIALS
But now, if we may hold this theory to be true for some specific dis-
eases, and not unreasonable for the rest, let us see how, in its terms, we
can explain or express the chief characters of these diseases ; such as
their periodicity, metastases, and metamorphoses, the apparent increase
of the specific substance in the blood, and the others just enumerated.
This may be done while tracing the probable history, or, as I would
call it, the life, of the morbid material in the blood, and in the tissues.*
Specific morbid materials, or at least their chief constituents, may
enter the body from without, by inoculation, contagion, or infection :
or they may be formed in the blood, or added to it within the body : in
other words, some morbid materials are inserted, others are inbred, in
the blood ; with some, probably, both modes of introduction are possible.
Doubtless, an important difierence is thus marked between two chief
groups of the specific diseases : but it is not within my present purpose
to dwell on it : for only one general history can as yet be written for
the whole class of morbid materials on which the specific diseases de-
pend : and, although this may be best drawn from the instances of those
that are derived from without, i. e., from such as are called morbid
poisons, yet it would probably be as true, in all essential features, for
those that are inbred.
When a morbid poison is inoculated, — for example, when the matter
from a syphilitic sore, or from a vaccine vesicle, is inserted in the
skin — it produces a specific efiect both on the tissue at the place of in-
sertion, and on the blood, as soon as it, or any part of it, is absorbed :
in other words, it produces both a local and a constitutional change ;
and in both these effects its history must be traced.
I. First, respecting the local changes of which, with another design,
I have already spoken (p. 303). It is not proved by anything that can
be seen immediately, or even within one or two days after the inocula-
tion. The place of inoculation remains, for a time, apparently unaf-
fected : and yet that a peculiar change is being wrought in it is clear,
for it presently becomes the seat of specific disease, the materials of
which disease are supplied by blood that nourishes healthily all other
parts, even such parts as may have received common injuries at or near
the time of the inoculation. The inoculated part, therefore, is not
merely injured, but is peculiarly altered in its relation to the blood,
which now nourishes it differently from all the rest of the body. The
change of the blood is proved, if not by general febrile or other disturb-
ance, yet by the specific character of the presently ensuing disease, and
by the consecutive secondary disease, or by consecutive immunity from
later disease of the same kind.
* Several of the characters of specific diseases are already explained, in the terms of this
theory, in the earlier Lectures: namely, their specific forms and constructions (pp. 40, 44,
63) ; symmetry and seats of election (p. 35, e. s.) ; extension and errantry (p. 37, note).
IN THB BLOOD AND TISSUES. 381
If farther proof be needed of the specific local change produced in
the inoculated part, it may be furnished by the analogy of the more
visible effects of certain animal poisons, — such as those of venomous
serpents and insects. None of these appear to be simple irritants ; the
consequences of their insertion are not like simple inflammations, but
are peculiar, and constant in their peculiarities. The bite of a bug or
a flea will not, I hope, be thought too trivial for an illustration.
In less than a minute after the bite, the bitten part begins to itch ;
and quickly after this, a wheal or circumscribed pale swelling, with *a
nearly level surface, and a defined border, gradually rises and extends
in the skin. It seems to be produced by an oedema of a small portion
of the cutis at and around the bite ; it is not a simple inflammatory
swelling ; it is, from the first, paler than the surrounding skin, which
may be healthy or slightly reddened by afllux of blood : and the con-
trast between them becomes more striking, as the surrounding skin
becomes gradually redder, as if with a more augmented fulness of the
bloodvessels. Thus, for some minutes, the wheal appears raised on a
more general, and less defined, vascular swelling of the surrounding
and subjacent tissues ; but, after these minutes, and as the itching sub-
sides, the wheal, or paler swelling, becomes less defined, and the more
general swelling appears gradually to encroach on it and involve it.
Then all subsides : but only for a time ; for in about twenty-four hours
a papule, or some form of secondary inflammation, appears, with re-
newed itching, at the seat of the puncture, and this after one, two, or
sometimes more days, gradually subsides.*
Now, the first pale and circumscribed swelling at any of these bites
may serve to illustrate the immediate effects of a morbid poison on the
tissues at and around the seat of inoculation. In the area of such a
swelling the tissues are, by the direct contact or influence of the venom,
altered in their nutritive relation to the blood. So, I believe, imme-
diately after the insertion of syphilitic, vaccine, or other virus, there
ensues a corresponding specific alteration of those parts of the sur-
rounding tissues which afterwards become seats of the specific local
disease-t
* Some penons are so happily constituted, that they do not thus, or with any other dis-
oomlbrt, suffer the consequences of insect-bites ; but I think the description I have given
will be found generally true for cases in which the bitten part is leA undisturbed ; the fortu-
nate exempt may illustrate the rarer exceptions from the usual influence of the severer
morlrid poisons.
f The direct influence of animal poisons on the tissues appears to be well shown in the
eflfeets of the bites of the viper and rattlesnake. Sir B. C. Brodie particularly noticed this
in m man bitten by a rattlesnake (Lectures on Pathology and Surgery, p. 345). The pri-
mary Vxai, though widely extended, elfect of the poison was a sloughing of the cellular
raembiane, which began ** immediately af\er the injury was received." The poison ^ seemed
to operate on the cellular membrane, neither in the direction of the nerves, nor in that of
ibe abeorbents, nor in that of the bloodvessels." His account has been recently confirmed
in a more quickly fatal case. Many years ago, one of my brothers was stung by a weever-
ilih (Tiaebions Draco) ; and I remember that next day, though no severe inflanmiation had
332 HISTOBY OF MORBID MATBBIALS
I will Dot venture to say that the secondary inflammation^ which
usually appears on the day after any of these bites, is to be ascribed in
some measure to an influence exercised by the virus on the blood ;
though, indeed, this will not seem impossible to those who are conside-
rate of the effect of the minutest portion of vaccine virus, and of the
intense\!onstitutional disturbance excited by the other venoms. But,
whatever be thought on this point, the occurrence of a new and different
inflammation in the bitten part proves that it did not return to perfect
health when its first affection subsided ; it proves that some altered
material of the virus, or some changing trace of its effects upon the tis-
sues, remained, altering their relation to the blood, and making them
alone, of all the parts of the body, prone to specific disease. The bitten
part thus, in its interval of apparent health, instructively illustrates the
state of parts after inoculation with syphilitic or vaccine virus. In
them, as in it, we must suppose that some virus, or some specific effect
produced by it on the tissues, remains during all that period of latency,
or incubation, as it is called, which intervenes between the inoculation
and the appearance of the specific disease.
Whatever be the state thus indirectly induced in the inoculated, or
bitten part, let it be noted as one constantly changing. The tissues of
the part, like the rest of the body, are engaged in the constant muta-
tions of nutrition ; and the morbid material in the part is probably,
like every organic matter, in constant process of transformation. Some
of the local phenomena of specific diseases indicate these progressive
changes in the part itself; but they can scarcely be traced separately
from those that are occurring in the morbid material absorbed in the
blood.
The local and peculiar change produced by the direct effect of the
morbid poison is essential to the complete manifestation of some specific
diseases. In many others, as in typhus, variola, acute rheumatism,
and gout, the morbid condition of the blood is sufficient to determine
the local disease in tissues previously healthy. But it is, perhaps, true
for all, that the existence of some part whose nutrition is depressed,
whether through simple or specific injury, is very favorable to the
manifestation of the constitutional disease (see p. 302). Thus, I shall
have to mention cases of cancer in which the constitutional condition,
or diathesis, seems to have been latent till some local injury brought a
certain part into a state apt for the cancerous growth, — the diathesis,
as one may say, waited for the necessary local condition. In like
manner, cases sometimes occur in which constitutional syphilis is justly
presumed to exist, but in which it has no local manifestation till some
part is appropriated for it by the effects of injury. I know a gentle-
man, who, for not less than five years after a syphilitic affection of the
testicle, had no sign of syphilis, except that of generally feeble health ;
intervened, there was a iittle black slough at the puncture, as if the venom had completely
killed a piece of the skin.
IN THE BLOOD AND TISSUES. 338
but he accidentally struck his nose severely, and at once a well-marked
syphilitic disease of its bones ensued. In another case, syphilitic dis-
ease of the skull followed an injury of the head. In similar cases,
ulcers like those of tertiary syphilis have appeared in healing operation-
wounds. I lately saw a gentleman who had long suffered with diabetes,
a condition with which, as is well known, boils often coincide. He,
however, had none, till he accidentally struck his leg, and the injury
was quickly followed by a succession of more than twenty boils near
the injured part. And, in like manner, as I have stated in a former
Lecture (p. 303), even variola and measles may have their intensest
local manifestations in injured parts. '
I need not dwell on the importance of cases such as these, for caution
against supposing that the diseases which seem to originate in local
injury are only local processes. The most intense constititutional
affections may appear almost irrespective of locality, able to manifest
themselves in nearly every part ; but the less intense may abide un-
observed, so long as all the tissues are being maintained without ex-
ternal hindrance or interference ; they may be able to manifest them-
selves only in some part whose normal power of maintenance is disturbed
by injury or other disease. It may, generally, also, be noticed that
the more intense the constitutional affection, and the less the need for
preparation of a locality for its manifestation, the less tenacious is it
of its primary seat. Contrast, for example, in this respect, the fuga-
city of acute rheumatism or gout with the tenacity of chronic rheuma-
tism in some locality of old disease or injury.*
II. Respecting, secondly, the changes which a morbid material,
inoculated and absorbed, may undergo in the blood, these may be enu-
merated as the chief, — increase, transformation, combination, and
separation or excretion. Here, again, one assumes for an example
such a morbid material as may be inoculated ; but it will be plain that
most of what is said, in the following illustrations, might also be said
of those that are otherwise introduced into the blood ; and further,
that the particulars of the life of these morbid materials are generally
consistent with those of ordinary constituents of the blood.
(a) The mcrease of the morbid material in the blood is illustrated in
syphilis, small-pox, vaccinia, glanders* In any of these, the inoculation
of the minutest portion of the virus is followed by the formation of one
or more suppurating structures, from which virus, similarly and equally
potent, is produced in million-fold quantity. So, the matter of any
contagion working in one person may render his exhalation capable of
similarly affecting a thousand others.
* Dr. CBrpenter (1. c.) has clearly traced that epidemic and other zymotic influences
bear, with peculiar force, on those in whose blood there is *' an accumulation of disintegra-
ting Aiotized compounds in a state of change." Is it not a similar degenerate condition
which makes an injured part peculiarly amenable to the influence of specific morbid mate-
rialt in the blood ?
334 HISTORY OF MORBID MATERIALS
The increase is thus evident. The effect of the inocalated morbid
poison may be compared with that of a ferment introduced into some
azotized compound, in some of the materials of which it excites such
changes as issue in the production of material like itself. What are
the materials of the blood thus changed and converted to the likeness
of the morbid poison we cannot tell. The observations of Dr. Carpen-
ter,* showing how peculiarly liable to all contagious and other zymotic
influences they are whose blood is surcharged with decomposing azotized
materials, may well lead us to believe that it is among these materials
that many of the morbid poisons find the means of their increase. And,
as Mr. Simonf argues, it seems nearly sure that certain of these
poisons, in their increase, so convert some material of the blood, that
they wholly exhaust it, and leave the blood for a long time, or for life,
incapable of being again affected by t&e same morbid poison.
The increase of the morbid material, however effected, explains these
characters of specific diseases : the apparent disproportion between the
specific cause and its effect (p. 326) ; the want of correspondence, in
respect of quantity, between the local and the constitutional phenomena
(p. 326) ; the seeming capacity of self-augmentation (p. 327).
(6) The transformation of a morbid material is indicated by the
diversity of the successive manifestation of a single and continuous
specific disease. Thus, in syphilis, the primary disease, if left to its
unhindered course, is followed, with general regularity, by a series of
secondary and tertiary diseases. The terms often used would imply
that these diseases are due to a morbid poison, which is, all along, one
and the same. But, identity of causes should be manifested in identity
of effects ; the succession of morbid processes proves a succession of
changes, either in the agent poison, or in the patient. They may be
in the latter ; but, regularly, they are in the former : for, on the whole,
the succession of secondary and tertiary syphilitic diseases is uniform
in even a great variety of patients. We may, therefore, believe, that
the regular syphilitic phenomena depend on the transformations of the
morbid poison : their irregularities, on the peculiarities of the patient,
whether natural or acquired from treatment.
The transformation here assumed is self-probable, seeing the analogy
of successive transformations in all organic living materials. It is
nearly proved by the different properties, in regard to communicability,
of the syphilitic poison at different periods : in the primary disease
communicable by inoculation, but not through the maternal blood to
the foetus ; in the secondary, having these relations reversed ; in the
tertiary, not at all communicable. In like manner, such facts as that
the material found in the vaccine vesicle, on the eighth day, is better
for fresh vaccinations than that taken earlier or later, prove successive
transformations, — periods, we may say, of development, maturity, and
degeneration, in the material of the virus.
* Log. cit. p. 159. f Lectures on Surgical Pathology, p. 262.
IN THE BLOOD AND TISSUES. 335
Many similar phenomena of transformations in the morbid poisons
may be cited ; and if it may be accepted as a general occurrence, it will
explain many of the phenomena of specific diseases. The period of
incubation or latency of a disease may correspond with the transforma-
tion preceding the effective state of the morbid poison, with its periods
of development. The prodromata, the precursive constitutional affec-
tions, and the successive stages of the disease, indicate the continuous
transformations and varying influences of the same; just as every
difference of organic construction indicates a difference in the yet un-
formed materials used in it. The increasing disturbance of the general
health probably implies that the morbid poison increases while being
transformed ; that it grows with its development. The periodicity of
all these events (p. 328) is a sign that the transformations of morbid
poisons, like those of all other materials in the living body, are, in
ordinary circumstances, accomplished in definite times. The sequelae
of specific diseases indicate yet further transformations, or, more pro-
bably, that the changes of the morbid poison have left the blood in a
morbid state, through the exhaustion of some of its natural constituents,
or through the presence of some complemental material.
(c) The cornUnation of a morbid poison with one or more of the nor-
mal materials of the blood is indicated by the fact, that when the same
specific disease, produced even by the inoculation of the same matter,
affects many persons, it may present in each of them certain peculiar
features. And these personal peculiarities, as they might be called,
indicate modified qualities of the disease ; not merely such differences
of quantity as might be explained by assuming that each person has,
in his blood, a different quantity of such material as may be convertible
into the morbid poison. Difference of quantity may explain (as Mr.
Simon and Dr. Carpenter have shown) difference of intensity of specific
disease, and difference of liability to epidemic influence ; but it does
not explain the varied method of the same disease in different persons.
For this, I believe, we must assume that the specific material of each
disease may be, in some measure, modified by its combination with one
or more of those normal materials of the blood which have, in each
person, a peculiar or personal character (see p. 34, e. s.)
By such combination, we may best explain those characters of specific
disease, which appear in its changes in transmission from one person to
another (page 327) : such as the varieties of syphilitic sores, and the
varieties of their consequences in different persons inoculated from the
same source ; the change in the form of secondary syphilis or of cancer
in transmission from parent to offspring ; the several peculiarities in the
results of the same miasm when affecting ordinary persons, or puerperal
women, or those who have survived injuries.
A remarkable instance, exemplifying, I think, as well the changes in
the morbid poison itself, as its various effects on different persons, has
been told me by my friend Mr. Huxley. One of the crew of H. M. S.
336 MORBID MATERIALS IN THE BLOOD AND TISSUES.
Rattlesnake, after slightly wounding his hand with a beef bone, had
suppuration of the axillary lymphatic glands, with which typhoid symp-
toms and delirium were associated, and proved fatal. His illness began
the day after the ship left Sydney, where all the crew had been remark-
ably healthy. A few days after his death, the sailor who washed his
clothes had similar symptoms of disease in the axilla, and, for four or
five months, he suffered with sloughings of portions of the areolar tis-
sue of the axilla, arm, and trunk on the same side. Near the same
time, a third sailor had diffuse inflammation and sloughing in the axilla;
and after this '* the disease ran, in various forms, through the ship's
company, between thirty and forty of whom were sometimes on the sick-
list at once." Some had diff^use cellular inflammation, some had inflam-
mation of the lymphatic glands of the head, axilla, or lower extremities ;
one had severe idiopathic erysipelas of the head and neck ; another had
phlegmonous erysipelas of the hand and arm after an accidental wound;
others had low fever, with or without enlargement of glands. "Finally,
the disease took the form of mumps, which affected almost everybody
on board/' The epidemic lasted from May to July. The ship was at
sea the whole time, and, in the greater part of it, in the intense cold of
a southern winter.
{d) The separation of the material of a specific disease may, probably,
be accomplished in many diffierent ways, and may be regarded as the
final purpose (if we may venture to trace one) of the greater part of the
morbid process. It is evident in the inoculable products of sores and
pustules; in the infectious exhalations of the skin, pulmonary, and
other surfaces in the exanthematous and other fevers ; in the deposits
in and near gouty joints. Analogy with these cases makes it, also,
probable that the specific materials of several other diseases are sepa-
rated from the blood accumulated at the seats of the local morbid pro-
cess ; whence, if no organisms incorporating them be constructed, they
may be reabsorbed after transformation. And it is nearly certain that
the materials of most specific diseases may be excreted with the natural
evacuations in the course of the disease, and this, either in their mature
state, or after transformation, or in combination with the constituents
of specific medicines.
The results of such separation or excretion are, also, various. Some-
times, it seems as if the whole of the morbid material were (after various
transformations) removed, and the blood left healthy : as in small-pox,
vaccinia', cured primary syphilis. Sometimes part of the morbid ma-
terial, transformed or combined, so as to be incapable of excretion,
remains in the blood, and produces secondary phenomena or sequelae
of the disease. Sometimes, the production of the morbid material con-
tinues, notwithstanding the separation of what is already formed ; as in
the increase of the cancerous diathesis during the growth of cancers.
Generally, in whatever manner the separation be accomplished, it is
attended by such disturbance of the natural functions of parts, that
CLASSIFICATION OF TUMORS. 887
serious disease is superadded to that which is the more direct conse-
quence of the presence of the morbid material in the blood. And
lastly, a local disease which owes its origin, and for a time its mainte-
nance, to a specific morbid condition of the blood, may persist after
that condition has ceased ; the blood may regain its health by the sepa-
ration of the morbid material, but the part diseased in the process of
separation may so continue. Now, however, the disease may be wholly
local, and curable by local treatment.
Thus may the theory of specific diseases be applied in explanation of
their phenomena. I will only add that, in assuming all this of the
changes occurring in morbid materials in the blood, we really assume
little more than we believe of the organizable materials introduced, as
nutriment, into the blood. If we could trace these, in their changes,
first in the. chyle and blood, and then in some complex tissue, then in
the lymph and blood again, and again through the tissue of some excre-
tory gland, we should trace a career of changes not less numerous, not
less definite in method and in time, not less influential in the economy,
than those which I have assumed for morbid materials in the blood.
Only, the increase of the morbid material, and the apparent indepen-
dence of its changes, are not imitated in the normal events of life.
LECTURE XXL
CLASSIFICATION OF TUMORS.
The class of diseases which includes the tumors may be reckoned as
^ part of the great division named Hypertrophies or Overgrowths. All
its members consist in additions to the organized materials of the body,
^nd appear to be expressions of a morbid excess of formative force ;
Wt, in the case of each hypertrophy, the mode is peculiar in which this
Excess is manifested. If we compare any tumor with one of the hyper-
trophies that are least morbid, with one of those, for instance, in which
the excessive growth is adapted to some emergency of disease, as an hy-
pertrophy of the heart is adapted to some emergency of the circulation,
ire shall, I believe, always see between them this chief difiFerence : that,
to whatever extent the adapted hypertrophy may proceed, the over-
grown part maintains itself in the normal type of shape and structure ;
while a tumor is essentially a deviation from the normal type of the
body in which it grows, and, in general, the longer it exists the wider
is the deviation. A striking illustration of this contrast may be found
in some of the cases of fibrous tumors that grow into the cavity of the
838 ' GENERAL CHABACTERS OF TUMORS.
uterus.'*' Such a tumor may resemble Id its tissues the substance of
the uterus itself, having well-formed muscular and fibrous tissues ; and,
so far as the structures formed in excess are concerned, we might regard
the tumor as the result of an hypertrophy not essentially different from
that which, at the same time and rate, may take place in the uterine
walls around it. But an essential difference is in this : the uterus, in
its growth around the tumor, maintains a normal type, though excited
to its growth, if we may so speak, by an abnormal stimulus : it exactly
unitates, in vascularity and muscular development, the pregnant uterus,
and may even acquire the like power ; and at length, by contractions,
like those of parturition, may expel the tumor, spontaneously separated.
But the tumor imitates in its growth no natural shape or construction:
the longer it continues the greater is its deformity. Neither may we
overlook the contrast in respect of purpose, or adaptation to the gene-
ral welfare of the body, which is as manifest in the increase of the uterus
as it is improbable in that of the tumor.
Herein we seem to discern an essential difference between the over-
growths of tumors, and those accomplished by any exercise of the
normal power of nutrition in a part. This power, capable of augmented
exercise in any emergency, is yet not a mere capacity of production ;
neither is it dependent upon circumstances for the fashion of its pro-
ducts ; identical with that which effected the development of the germ,
it is equally bound to conformity with the proper type of the part or
species in which it is exercised.
An equal contrast may, in general, be drawn between the class of
diseases that include tumors, and all the others that issue in a morbid
excess of nutritive formation. We may take, as the example of these,
the inflammatory diseases attended with exudation, and say (reserving
certain conditions, p. 295) that in these there is an excessive exercise of
formative force — an hypertrophy. But between such diseases and
tumors we shall rarely fail to observe the following differences : Ist
The accumulation and increase of lymph in inflammation appears chiefly
due to ihe morbid state of the parts at, or adjacent to, the place of ex-
udation. We have, I think, no evidence that the lymph of inflammation
increases by any inherent force, any attraction of self-organizing mat-
ter; but the increase of all, or nearly all, tumors, is "of themselves:"
they grow as parts of the body, but by their own inherent force, and
depend on the surrounding parts for little more than the supply of
blood, from which they may appropriate materials. A tumor, there-
fore, as a general rule, increases constantly ; an inflammatory exudation
generally increases only so long as the disease in the adjacent parts
continues.
2d. The materials severally produced in excess, in these two cases,
* Such as («. ff.) No. 2682 in the College Museum. Respecting the conditions in which
the changes in the uterus here described are likely to occur, see Rokitansky, Putliologische
Anatomie, iii, 546.
GENERAL CHARACTERS OF TUMORS. 839
have different capacities of deyelopment. The inflammatory exudation,
in whatever part it lies, has scarcely more than the single capacity to
form, in the first instance, connective tissue : the material that begins
or is added to a tumor may, indeed, assume this form, but it may assume
any one of several other forms.
But, Sdly, the most striking contrast is in the events subsequent to
this first organizing of the two materials. The latter course of organ-
ized inflammatory exudations, like that of the organized material for
repair after injuries, is usually one of constant approximation to a
healthy state. As newly-formed parts, they gradually assimilate them-
selves to the shape and purpose, if not to the tissue, of the parts among
which they lie ; or they are apt to waste, degenerate, and be removed.
Their changes tend ever towards a better state ; so that, in the whole
course of exudative inflammatory diseases, some can see nothing but an
"effort of nature" to avert or repair some greater evil.* It is very
different with the class of diseases to which tumors belong : it is in their
very nature to proceed to further and further deviation from the proper
type of the body. The structure of tumors may, indeed, be like that
of some of the natural parts ; it may be identical with that of the part
in which they lie : in this respect they may be called homologous ; but,
considered in their life, they are not so ; for, commonly, they are grow-
ing while the tissues far and near around them are only maintaining
their integrity, or are even degenerating, or yielding themselves to the
abnormal growth.
I think that it is only in the consideration of this activity and partial
independence of the life of tumors, and of the diseases allied to them,
that we shall ever discern their true nature. We too much limit the
grounds of pathology, when, examining a tumor after removal, we only
now compare it with the natural tissues. The knowledge of all its pre-
sent properties may leave us ignorant of the property which it alone, of
all the components of the body, had some time ago, — the property of
growing. And so, if we can ever attain the knowledge of the origin of
a tumor, it may avail little, unless it supply also the explanation of its
progress. If, for example, what is very improbable could be proved,
namely, that tumors have their origin in the organization of extrava-
sated blood, or of an inflammatory exudation, still this greater problem
would remain unsolved : How or why is it, that, in ordinary cases,
these materials, when organized, gradually decrease, and assimilate
themselves to the adjacent parts ; while, in the assumed formation of
tumors, they gradually increase, and pursue, in many cases, a peculiar
method of development and growth ? Why is it that, assuming even a
similarity of origin, the new-formed part manifests, in the one class of
cases, a continuous tendency towards conformity with the type of the
* There are, indeed, cases in which organized lymph and scars continue to grow ; bat
theie aia qaite exceptional, and are to be regarded as diseases of the same class as tumors,
p0CDUar odIj in respect of the materials in which they are manifested.
340 GENERAL CHARACTERS OF TUMORS.
body ; in the other, a continuous deviation from it in shape and volume,
if not in texture ? How is it that, to take an extreme case, we can
ever find, as in a specimen* at St. George's Hospital, fatty tumors of
considerable size in the mesentery of a patient from whom, in the ex-
tremest emaciation of phthisis, nearly a,ll the natural fat was removed ;
or, as in a case related by Schuh,t huge lumps of fat, on the head,
throat, and chest of a man whose abdomen and legs were extremely
thin ?
I do not pretend to answer these questions ; but I think that in them
is the touchstone by which we may tell the value of a pathology of this
great class of diseases. It is not in the likeness or in the unlikeness to
the natural tissues that we can express the true nature of tumors : it is
not enough to consider their anatomy ; their physiology, also, must be
studied ; as dead masses, or as growths achieved, they may be called
like or unlike the rest of a part ; but, as things growing, they are all
unlike it. It is, therefore, not enough to think of them as hypertrophies
or overgrowths : they must be considered as parts overgrowing, and as
overgrowing with appearance of inherent power, irrespective of. the
growing or maintenance of the rest of the body, discordant from its nor-
mal type, and with no seeming purpose.
To all this, I know, it may be objected that tumors, and other like
growths, may cease to grow, or grow unequally, and yet be tumors still.
But this is only in appearance opposed to what I have said, which is no
more than that the best or only time, in which we may discern the true
diflFerence of these from other growths, is the time of their active in-
crease. As we can have no complete idea of any living thing, unless
it include the recognition of its origin, and of its passage through certain
phases of development and growth ; so must our thoughts of these ab-
normities be imperfect or untrue, unless we have regard to their de-
velopment and growth, and maintenance, as independent parts. But,
indeed, the cessation of growth in tumors and the allied diseases often
affords evidences of their peculiar nature, confirmatory of that deduced
from their increase. Such cessation may occur when they have attained
a certain regular size ; as in the painful subcutaneous tumors, the osse-
ous tumors on the phalanges of great toes, and some others, which,
perhaps always, cease to grow when they have reached a limit of dimen-
sions that appears as natural and constant for them as the average
stature is for the individuals of any species. Or, the cessation of growth
may occur when the tumor degenerates or wastes ; as when a fibrous
tumor calcifies, or when a mammary grandular tumor is absorbed. But
it is to be observed that these events are, or may be, as irrespective of
the nutrition of all the rest of the body, as the development and growth
of the tumor were ; and that, except in the comparatively rare event of
the absorption of a tumor, there is, in no case, an indication of return
* Y. 71, Museum of St. George's Hospital.
f Die Erkenntniss der Pseudoplasp. 101. Wien, 1851.
GENERAL CHARACTERS OF TUMORS. 341
to the normal type or condition of the body : there is no improvement,
&8 in the organized lymph formed in the inflammatory process, no adap-
tation to purpose, no assumption of a more natural shape. In all these
events, therefore, as well as in their growth, the nearly independent
nature of the tumor is shown : while forming part of the body, and
borrowing from it the apparatus and the materials necessary to its life
the tumor grows or maintains itself, or degenerates, according to pecu-
liar laws.
The characters of which I have been speaking belong to a larger
number of abnormities than are usually called tumors : they belong, in-
deed, to a large class, of which tumors form one part or section, while
the other is composed of certain morbid enlargements of organs, by what
is regarded as merely hypertrophy ; such as that of the prostate, the
thyroid gland, and others.* Now the distinction between these two
divisions of the class must, I believe, be an arbitrary one ; for the two
are so little unlike, that, really, it is in these hypertrophies of glands
that we may hope to find the truest guidance to an insight into the
nature of tumors.
In speaking of cysts from the walls of which vascular growths may
spring and fill their cavities, I shall have to describe that these intra-
cystic growths are, in their best state of structure, close imitations of
the gland in which they occur. In relation to tumors, the most instruc-
tive examples of this fact are in the cystic tumors of the breast, of which
the general structure has been especially illustrated by Dr. Hodgkin
and Sir B. C. Brodie, and the microscopic characters by M. Lebert and
Mr. Birkett. Among these, a series of specimens in the Museumf may
illustrate every stage of the transition, from the simple cyst, to the cyst
so filled with gland substance as to form a solid tumor, — the chronic
mammary, or mammary glandular tumor. Now a near parallel with the
history of these mammary tumors is presented by the observations of
FrerichfiJ and Rokitansky§ on the intra-cystic growths which occur
* The class may seem to include, also, those abnormal states of the fcetus which are at-
tended with excessive growth or development of organs or members, yet cannot be ascribed
to a fockm of two germs; and, indeed, in the case of certain bony growths, the line cannot
be drawn, without artifice, between monstrosities by excess and tumors. But, in the large
majority of cases, there are sufficient characters of distinction between them; for, 1st, the
coogemtal excesses of development present a more complex structure, and are more con-
formed to the plan and construction of the body, than anything that can be reasonably called
m tDmoir. And if it be said that this higher organization is no more than is consistent with
the period of formation, which is in embryo-life, when the force of development is greatest,
then, 2dly, we may note this difference : that the congenital excesses are usually limited for
their increase to the i>eriod of natural growth of the body. They commonly cease to grow
when or before the body has attained its full stature ; they conform to its methods and times
of deTelopment, growth, and decay.
t Mas. Coll. Surg., Nos. 168, 169, 170, 172, &c.
X Ueber Gallert-oder CoUoid-geschwQlste. Gottingen, 1847.
{ Zur Anatomie des Kropfes ; and Ueber die Cyste, in the Denkschr. der K. Akademie
der WjMenKbaften, Wien, 1849.
842 DISTINCTIONS OP INNOCENT
within the substance* of enlarging thyroid glands, t. e.j of increasing
bronchoceles. In these, masses of new-formed thyroid gland-tissne are
found imbedded, and inclosed in coverings or capsules of connectiye tis-
sue, within the proper though increased substance of the gland. In like
manner, as Rokitansky first showed, it is not unusual, in enlargements
of the prostate gland, to find distinct masses of new structure imitating
that of the prostate, which lie imbedded and incapsuled in the proper
substance of the gland. Moreover (and here is a closer contact between
these hypertrophies and tumors), these growths of new gland-tissue may
appear, not only in the substance of the enlarging thyroid and prostate
glands, but external to and detached from the glands. Such outlying
masses of thyroid gland are not rare near bronchoceles ; lying by them
like the little spleens one often sees near the larger mass. Near the
enlarged prostate, similar detached outlying masses of new substance,
like tumors in their shape and relations, and like prostate gland in tis-
sue, may be sometimes found. A very large and remarkable specimen
of the kind was sent to me by Mr. Wyman.'*' It was taken from a man,
64 years old, who, for the last four years of his life, was unable to pass
his urine without the help of the catheter. He died with bronchitis ; and
a tumor, measuring 2^ inches by 1^, was found, as Mr. Wyman de-
scribed it, " lying loose in the bladder, only connected to it by a pedicle,
moving on this like a hinge, and, when pressed forwards, obstructing the
orifice of the urethra." Now, both in general aspect and in micro-
scopic structure, this tumor is so like a portion of enlarged prostate
gland, that I know no character by which to distinguish them.
The relation of these new-formed isolated portions of thyroid or pro-
state gland is so intimate, on the one side, to admitted tumors, such as
the chronic mammary, and, on the other side, to the general hypertro-
phies of the glands, that we cannot dissociate these diseases without
great violence to nature. Clearly these are all essentially the same
kind of disease : yet, to call them all "tumors" would be to do as much
violence to the conventional use of terms which have become not merely
the expressions, but the guides, of our thoughts. The best course seems
to be to make an arbitrary division of this group. In accordance, then,
with the arbitration of custom, we may assign the name of tumors
such examples of these morbid growths or growing parts, as, 1st,
isolated from the surrounding parts by distinct investing layers o
tissue ; or, 2dly, though continuous with the natural parts, are abrupt!
circumscribed in the greater part of their extent; or, 3dly, are formed of
new materials infiltrated and growing in the interstices of natural parts.
If the group of what are to be called tumors may be thus inclosed^
we may next proceed to divide it into smaller parts. And, first, it
* The specimen is in the Museum of St. Bartholomew's Hospital. A remarkable inmor
of the same kind, but imbedded in the substance of the prostate, is in the Museum of the
Middlesex Hospital.
AKD MALIONANT TUMOBS. 843
seems proper to divide tamors into two principal divisions, according as
they may be named innocent or malignant, and a third intermediate
group of snch as may be named recurrent. I would employ the terms
innocent or malignant still, because, though not free from objections,
they imply a more natural and a less untrue division than any yet
invented to replace them. The distinction between innocent and ma-
lignant tumors is probably one, not of mere visible structure, but of
origin and vital properties ; it is, therefore, less falsely expressed by
terms implying quality of nature than by such as refer to structure
alone.
The chief distinctions are to be traced in certain characters which, in
the malignant tumors or cancers (for these terms are synonymous), are
superadded to those already cited ^s belonging to the whole class.
And, 1st, the intimate structure of malignant tumors is, usually, not
like that of any of the fully developed natural parts of the body, nor
like that which is formed in a natural process of repair or degeneration.
Many of the cells of cancers, for example, may be somewhat like
gland-cells, or like epithelium-cells ; yet a practised eye can distinguish
them, even singly. And much more plainly their grouping distin-
guishes them ; they are heaped together disorderly, and seldom have
any lobular or laminar arrangement, such as exists in the natural glands
and epithelia, or in the innocent glandular or epithelial or epidermal
tumors. These innocent tumors are really imitations, so far as their
structure is concerned, of the natural parts ; and the existence of such
imitations in any tumors makes the diversity — the heterology, as it is
called — of the malignant tumors, appear more evident.
Still, this rule of dissimilarity of structure in malignant tumors is
only general. The other properties of malignancy may be sometimes
observed in tumors that have, apparently, the same structure as those
that are generally innocent. I shall have to refer to cases of fibrous
tumors which, in every respect of structure, were like common fibrous
tumors, and yet returned after removal, and ulcerated, with infection
of adjacent parts, and appeared in internal organs. These, with some
others, must be regarded as malignant, though in structure resembling
innocent tumors and natural tissues. On the othet hand, there are
some innocent cartilaginous tumors, with structures as different from
those that exist in our natural tissues, as cancer-cells are from gland-
cells, or from epithelial-cells. The two sets of cases, though both be
exceptional, supply sufficient grounds for not preferring such terms as
'* homologous" and "heterologous" before "innocent" and "malig-
nant," if the former are meant, as they commonly are, to apply to the
structure of the several growths.
2d. Malignant growths may have the character of infiltrations ; i, e.
their elementary structures may be inserted, infiltrated, or diffused in
the interspaces and cavities of the tissues in which they lie. Thus, in
its early state, a malignant tumor may comprise, with its own proper
elements, tfaoae of the organ in which it is formed ; and it U onl; b ita
later life that the elementa of the tii»sue or organ disappeftr froa it,
gradually degenerating and being absorbed, or, pottiiibly, ^ieldinj tbfv.
selves as materials for its growth."
Thus, a hard cancer of the mammary gland includes in ita tDui t
part, or even the whole, of the gland itself, as If there were only 4 wo-
version of the gland- 1 issue : and one maj find, within the veryni- I
stance of the cancer, the remnins of the lactifurous tubes iuroUeiliB '
it, and, with the microscope, may trace in it the connective tiwue tku
separated the gland-lobes, and the degenerate elements of the epithtliil
contents of the tubes and acini. But among all these lie tbc pra|i«t
cells of the cancerous growth, and these usually increase while tit
original structures of the gland decrease. So, too, in medullary cmoer-
ous disease of the uterus, the uterus itself, or part of it, i« la llu
tumor, and gradually wastes, while the medullary matter, difmcd v
infiltrated in it, is growing.
The malignant growths may, I say, thus appear as infiltraliou; bit
they are not always so. Thus, though the hard cancer of the brcul
is, commonly or always, an intiltration of cancerous substance in uul
among the proper structures of the gland, yet the hard cancer uf ibt
bones is often a distinct tumor, such as has no mixture of bone io it,
and may be enucleated from the cavity or shell of bone in which ii lit><
So, too, while the medullary cancer of the uterus plainly consists to u
infiltration or insertion of new material in the substance of the orgu.
that of the breast is usually a separate tumor, and altogether ditctt*
tinuous from the surrounding parts.f
Many other instances of similar contrast might be cite<l; sliU ik
fact that their elementary structures may be thus infiltrated in theti^
sues they affect is a characteristic of malignant tumors. I think il i*
rarely imitated in cases of innocent tumors.
3d. It is, also, generally characteristic of malignant tumors that tkcf
have a peculiar tendency to ulcerate, their ulceration being preceded
by softening. One can, indeed, in this particular, only obMrrc *
graduated difference between the innocent and the malignant diKWOi
for certain innocent tumors, if they grow very rapidly, aro apt "tj
rapidly to decay ; and they may suppurate and discharge their iek"
and d(!bris with foul and dangerous ulceration. Thus the qoi^,^*
growing cartilaginous tumors may imitate, in these respects, mah'gBUit
growths ; so may large fibrous tumors when they soften and decay. Or*
• See, on iliis lan-meniior>»l point, Roliimnaky, P.iliol. Anniomie, i, Vil. It iim^ •
■iun of ihn n«w motlnJ tubUBncc, lliere may be no (welling oi viuble tumor; jnl, tlu*^
IMW in«lerAl iocreues, the eaMnlinl cliinctec of > giowih ii abaervotl. Soeb (to*!*
wilLoui BWelling is ollen noiiced in hardcanceta of the biCRil and of Uic bonai-
t Not. 278T, ^-Qd, and oiben in ibe CotkRe Miiteum ; aad No>. IS in Sar, n,tad1***
Ser. 35, of ihst of Si. BBrtliDlamew't, illuilraie ihe»e
ntfUlraliimt ltd mUgnnBtkt, tee p. 3S7.
AND MALIGNANT TUMORS. 345
again, when an innocent tumor grows more rapidly than the parts over
it can yield, they may waste and ulcerate, and allow it to protrude ;
and it may now itself ulcerate, and look very like malignant dis-
ease. This may be seen in the protruding fibrous tumors that ulce-
rate and bleed ; or, in a more striking manner, in the protruding vas-
cular growths that have sprung up in the cystic tumors of the breast.
Or, once more, the characters of readiness to ulcerate may be imitated
by innocent tumors after injuries, or in exposure to continued irrita-
tion ; for they resist these things with less force than the similar natu-
ral parts do. Hence, sloughing and ulcerating fibrous, erectile, and
other tumors, have been often thought cancerous, and so described.
The respective tendencies to ulcerate can, therefore, be counted only
as constituting differences of degree between the innocent and malig-
nant tumors. We may speak of a liability in the one case, of a prone-
ness in the other. '
4th. The softening that often precedes the ulceration of malignant
growths, can hardly be considered separately from the minute account
of their structure. I therefore pass it by, and proceed to their fourth
distinctive character, which is to be noticed in the modes of their ul-
ceration.
This is, that the ulcer which forms in, or succeeds, a malignant
growth, has no apparent disposition to heal ; but a morbid substance,
like that of which the original growth was composed, forms the walls or
boundaries of the ulcer ; and as this substance passes through the same
process of ulceration which the primary growth passed through, so the
malignant ulcer spreads and makes its way through tissues of all kinds.
In contrast with this character of malignant growths, it is observable
that beneath and around an ordinary ulcer of the natural tissues, or of
%n innocent tumor, we find the proper tissues unchanged ; or, perhaps,
infiltrated and succulent with recent lymph, or the materials for repair ;
or somewhat indurated with lymph already organized. The base and
tnargins of a cancerous ulcer are themselves also cancerous : those of a
Qommon ulcer are infiltrated with only reparative or inflammatory
^naterial. In like manner, if ulceration extend through an innocent
^owth, it may destroy it all, and no similar growth will form in the
adjacent parts, replacing that which has been destroyed ; but, in the
ulceration of cancer, while the cancerous matter is being constantly
discharged, by sloughing or ulceration, from the surface, new matter
of the same kind, and in more abundance, is being formed at some dis-
tance from the surface; so that, in a section through an ulcerated
cancer, one does not arrive at healthy tissues till after passing through
a stratum of cancer.
5th. Malignant tumors are, again, characterized by this : that they
not only enlarge, but apparently multiply or propagate themselves ; so
that, after one has existed for some time, or has been extirpated, others
23
DISTIHCTIOirS OF IKROCIBT
like it grow, either in widening circles ronnd its seat, or tn [
remote.
Mere multiplicity is not a distinctive character of malignant diwwm
for many innocent tumors may be found in the snmc person. But ii
the conditions and circumstances of the multiplicity there are chanM
tcvistic differences. Thus, when many innocent tumors exiit in tb
same person, they are comiQonly„or always, all in one tissue. A m»i
may have a hundred fatty tumoru, but they shall all be in bia snbcri
taneous fat : many fibrous tumors may exist in the same utvrun, bat I
is BO rare, that we muy call it chance, if on<> bo found in any other ]»r
in the same patient : so, many cartilaginous tumors may be in theboiM
of the hands and feet, but to these, or to these and the adjacent boDM,
they are limited.
There is no such limitation in the cases of multiplicity of naligmDl
tumors. They tend especially to affect the lymphatics connected wilk
the part in which they first arise: but they are not limited to th»«.
The breast, the lymphatics, the skin and muscles, the liver, the IvJip,
may be all, and at once, the seats of tumors. Indeed (and here imbt
chief contrast), it is more common to find the many malignant tumor)
scattered through severnl organs or tissues than to find them limiuJ
to one,*
Moreover, if there be a multiplicity of innocent tamors. they kin
generally a contemporary origin, and all seem to make (at least for*
time) a commensurate progress. But the more onliniiry coorM <if
malignant tumors is, that one first appears, and then, after ■ clnr
interval of progress in it, others appear ; and these are foUowei] I7
others, which, with an accelerating succession, spring up in difftMrt
parts.
t!th. A sixth distinctive character of , malignant tumors la lhat,ii
their multiplication, as well as in their progress of ulceration, lli«nit
scarcely a tissue or an organ which they may not invade.
In regard to their multiplicity, I have just illustrated their ooatnH
in this point with the innocent tumors; and a similar contraM ii"
obyions in the characters of the ulcers. It is seldom that a oomBN
ulcer extends, without sloughing, from the tissues it has first tSvMi
into any other ; rather, as a new tissue is approached, it is tbicketifJ
and indurated, as'if to resist the progress of the ulcer. But befoM*
cancerous ulcer the tissues in succoftsion all give way, beooming (tft
infiltrated, and then, layer after layer, degenerating and iiloenitiR|
away with the cancerous matter.
One may see this very well in bones. Specimens are to be foW ■*
■ A oue quoted in die Ai>nc. Meil. Jal. N»v. 30, 18.'>5. ffDin ihe pnciin of Dl >■ *-
SmillM offen m remnrkablp e»co|uiori lu ihiii nile. A wom«>i, wiilj cibaoleta ieinbBi«^*
uf ihe liteail. liaJ (econdary toirrliui in neaily every pan of tlic ikelaion. Bikl xMiV'
AND MALIGNANT TUMORS. 847
nearly all Museums, of tibiae (for example) on the front surfaces of
which new bone is formed, in a circumscribed round or oval layer, a
line or two in thickness. This bone, which is compact, hard, smooth,
and closely united with the shaft beneath it, was formed under an old
ulcer of the integuments of the shin. But, on the other side, specimens
are found, which show that when a cancerous ulcer reaches bone, at
once the bone clears away before it ; and a cavity with abrupt, jagged,
eaten-out edges, tells the rapid work of destruction.* Neither are
specimens rare, showing the progressive destruction of more various
tissues ; such as a cancer of the scalp making way by ulceration through
the pericranium, skull, and dura mater, and then penetrating deeply
into the brain ;t or one in the integuments of the shin going right
through the tibia, and deep into the muscles of the calf.|
Such are the general characters of malignant tumors. Those of in-
nocent ones are their opposites or negatives. Thus : innocent tumors
have not a structure widely different from that of a natural tissue ; they
do not appear as infiltrations displacing or overwhelming the original
tissues of their seat ; they do not show a natural proneness to ulcera-
tion : nor is the ulceration, which may happen in one through injury
or disease, prone to extend into the adjacent parts : they do not appear
capable of multiplying or propagating themselves in distant parts : they
do not grow at the same time in many different tissues.
Of recurrent tumors the chief distinctive characters are that, like
innocent tumors, their structures resemble those of natural tissues, but
only in a rudimental state, or in conditions that may be likened to
malformations : that they do not appear as infiltrations ; that their
ulceration, to which, however, they are more prone than most innocent
tumors, is not apt to extend into adjacent parts : but that, like malig-
nant tumors, they do sometimes appear in organs distant from their
first seat, and are exceedingly prone to be repeatedly formed after
complete extirpation.
flow, the distinctive value of each of these characteristics of malig-
nant disease may be depreciated : indeed, I have myself lowered it, by
showing that each of them may be absent in tumors having all the
other features of malignancy, and that certain of them may be observed
occasionally in tumors that in other respects appear non-malignant.
Sat objections against each character separated from the rest are of
little weight against the total value of all these characters of malig-
nancy, or of a majority of them, concurrent in one case. Similar
objections might be made against even the classifications of natural
Idstory : and none but such as are disposed to cavil at all nosology,
could fail, in watching a series of cases of tumors through many years,
* Id the College Museum, Nos. 3082-3-3 A; 3267-8, and many others, illustrate these
points,
f Maseom of St. Bartholomew's, vi, 57.
X MufleoRi of the College of Surgeons, 232.
S48 DIBTINOTIQNS OF IRNOCIRT
to observe that ttie great majority of them could be clKssed icmriia*
an, in their course, ihcy did or did not present the charMten that f
have enumerated. Some cases would lie found in which one or two of
the cigns might he wanting, or. if I may so speak, misp)»oe<l; bm,
putting these aside, as exceptions to he reguhited by future inqniry,
and looking broadly at the whole subject, no one could doaht ibst An
division of tumors into innocent and malignant may be justly litid«,
and that the outward murks by which they are discriminated an ti-
pressions of real differences in their properties and import.
In what these dilferences may consist I shall not discuss tillllwn
completed my account of each kind of tumor. For the pre«ei>( I wiH
say only, that I think malignant tumors are local manifestatioiyi of
some specific morbid states of the blood; and that in them arrism-
porated peculiar morbid materials which accumulate in the blood, ud
which their growth may lend to increase. All their di8tinctiteebRn6
tera are, I think, consistent with this view: and the nbeencooTibt
characters in innocent tumors may lead us to believe that therm
usually local diseases, the result of some inexplicable error of natriliai
in the part that they affect, and only in the same measure dep«ii<ii'M
on the state of the blood as are the natural tissues, which require, iid
may be favored by, the presence of their Appropriate materials of W-
tritlon. Or, when, as sometimes happens, an innocent tumor begmaiu
growth during, or soon after, some general disease, we may stipp**
that it owes its first formation to an abnormal condition of the blond:
but that, when the blood recovers its health, the tnmor subsiw or
grows on the nourishment supplied by the normal materials of Af
blood. Instances of tumors thus constitutional in their origin, bit
subsisting as local diseases, will be mentioned in the general htstorj^
cancers.
It may be best to speculate no further, either on this point, <w «
the origin or determining causes of tumors. I could 8pe>k certaiBlj
of very little connected with these points, unless it were of the errt *
insufficiency of all the hypotheses concerning them that I hare pro[w«i
to myself, or have read in the works of others. One of these alone ■»<■•
to need disproof; namely, that tumors, whether innocent or malignut.
are due to the organization of effused blood, or of some inflaimnawfj"
or other exudation, or of the material of repair. The great objeeOM*
to this view are as follows: 1. It is an almost infinitely small pr«p«^
tion of injuries that are followed hy the growth of tumors, i. In*
large majority of cases of tumor, no injury or prcvioua local diiia**
is assigned, even by the patients, ns the cause of the growth, la*"*'
cases, taken indiscriminately from those I have lately rccorJfd, <>*
local cause whatever could be assigned for the growth of 155 iiunui*-
of which 64 were innocent and 91 malignant; of the remaining 46,^
ferred by the patients to previous injury or disease of the part, IS «•*
innocent and SO malignant tumors. 3. Blood extravasated, tai ^
AND MALIGNANT TUMORS. 349
products of the inflammatory and reparative processes, are not indif-
ferent materials, such as would pursue this or that direction of develop-
ment, according to chance, or some imaginary influence exercised on
them. They have a proper tendency to assume the form of connective,
or osseous tissue. They do not become, when their history can be
traced, either fatty, or perfectly cartilaginous, or glandular tissue, such
as we find in tumors. 4. No intermediate conditions have been yet
found between blood, or lymph, and a tumor. And, lastly, all the
facts relating to injuries, as favoring, or determining, the growth of
tumors, are explicable on the supposition that the injury impairs for
a time the nutrition of a part, and diminishes its power of excluding
abnormal methods of nutrition.
Narrowing, now, the objects of consideration to the innocent tumors
alone, I will speak very briefly of their classification.
A first subdivision of them may be made, according to the usual
arrangement, into the cysts, or cystic tumors, and the solid tumors.
There are, indeed, not a few instances in which the two divisions over-
lap, or are confused. Thus, on the one side, in cases to which I have
already referred, a solid growth may spring from the inner walls of a
cyst, and, enlarging more rapidly than the walls do, may fill the cavity,
and come in contact and unite with the walls ; and thus may be traced
a complete series of gradations from the cystic to the solid tumor.
On the other hand, cysts may be formed within solid tumors, and, in-
creasing more rapidly than the solid structure, may reduce it to scarcely
more than a congeries of cysts, or to one great cyst. Such changes
are illustrated sometimes in fibrous tumors of the uterus ; and I think,
also, in the tumors which Sir Astley Cooper called ^* hydatid disease "
of the testicle.
But though there are these instances of confusion, yet the division
is very convenient, and is probably deeply and well founded.
Next, among cysts, some are filled with a simple fluid, containing no
organized matter, and resembling one, or other, of the fluids of serous
cavities. These may be called simple or barren, or, in most instances,
Berous cysts.
Other cysts contain organized substances, and may be named, as a
group, proliferous ; and the several members of the group may be de-
scribed, according to their contents, as glandular, cutaneous, sebaceous,
dental, and the like.
Of the solid innocent tumors, no method of arrangement at present
appears reasonable but the old one, which is founded on their likeness
to the natural tissues. On this ground they may be arranged in the
following divisions, with names, as specific names, expressing their seve-
ral resemblances, — ^viz., fatty, fibro-cellular, fibrous, fibroid, and fibro-
nucleited, cartilaginous, myeloid, osseous, glandular, and vascular or
erectile. And, again, under each of these may be arranged certain
varietieSi including instances that, in some uniform manner, deviate,
without quite departing, from the usual characters ; as tb« SbrM^nic,
fibro- calcareous, and other varieties of the fibrous tumors.
In each assumed kind or group of these solid tumors, moreoTsr, n
must make a division, according to their modes of growth, Knd of con-
nection with the adjacent parts. Some among them are onlv iBt^r-
mediately connected with the adjacent parts ; a la^'cr of tissue si ohm
separates and combines them, and, hj division of thix laver, soeh t
tumor may be cleanly and ftlone removed from the surrounding put);
it may bo enucleated or shelled out from them. Thus, with a comnion
fatty tumor, or a fibrous tumor of the uterus, if we out along ooe pM
of its surface, we may, with a blunt instrument, dctsch the whole bwm,
hy splitting the layer of connective tissue which, like a capaakib-
closes and isolates it.
These are what we commonly accept as the proper or typical tUBon,
these which are "discontinuous hypertrophies."
Other growths resemble these !n every character, except in thai ili*y
are connected with the adjacent pans by continuity of simitar tiMw.
and thus appenr ns growths, not in, but of, the parts. Thus we canoM
exactly isolute a polypus of the nose or of the uterus : the overgnm
part cannot be enucleated, because the proper tissue of the nasal bb-
C0U8 membrane, or of the uterine wall, is continued into it; the time
of the growth is here not only uniform, but continuous, with that of tlu
adjacent parts. So, too, with epulis : the gum itself, or (he perioetwB
of the jaw together with the gum, seems, by its own excessive growit
to form the tumor ; and in other fibrous tumors on bones, the fibre* of
the periosteum appear to be in the growth, and to form part of it
Such growths as these might be named "continuous hypertroplw*,"
or "outgrowths;" and I will, in general, observe this distinction i^*
ever the same tissue is, in different cases, found in both forms of groiti;
culling the discontinuous masses, tumors, and the continuous OD(«,H^
growths. Thus, answering to the common fatty tumor, we find the pa-
dnlous and continuous fatty outgrowths of the neck or the abdoniul
walls; answering to the fibro-celtular tumor that grows, as a ^Hn-
tinuous mass, in the scrotum or beneath the labia, we have the €sl»-
neous outgrowths or enlargements of these parts ; to the fibrous tunns
of the uterus answer the fibrous polypi or continuous outgrowths Dfif
substance. All these instances of clear distinction might lead n to
think that a strong definition-line might be drawn to divide the wi"!*
class of innocent overgrowths into tumors and outgrowths. But 'Iw
we come to the tumors of bone and periosteum, and to the erwlif*
tumors, we find the distinctions vanishing, and tn many instaucM bo
longer possible.
It may seem as if these " outgrowths" needed distinction from lli*
" infiltrations" which were spoken of as peculiar to mslignsnt di««*
The distinctions between them are well marked. In the outgrowth tb«
new material is like that with which it is connected, or like its n«r»*'
AND MALIGNANT TUMORS. 351
rudiment, so that it is as if the tissue were itself outgrown ; but, in the
infiltration, the new material is dissimilar from that in the interstices
of which it is placed. And in the outgrowth the materials of the ori-
ginal part appear to be at least maintained, if they are not increased ;
but in the infiltration they degenerate and waste. We may compare,
for this contrast, the cancerous diseases of the skin, with the cutaneous
outgrowths of the labia, nymphse, prepuce, or scrotum.
In thus briefly indicating that which appears still the most reasonable
method of classifying tumors, I have referred to difficulties which have
appeared to some to be insuperable objections to any attempt at an
arrangement of these diseases. I will therefore state, so far as I can,
what is the real weight of these objections. "*"
First, it is said, such classifications cannot be well made, because,
between each two assumed kinds or groups of tumors, intermediate ex-
amples may be found transitional, as it were, from one species to the
other: the one, it is said, "runs into" the other; or, as Mr. Abernethy
expressed it, "diseases resemble colors in this respect, — that a few of
the primary ones only can be discriminated and expressed, whilst the
intermediate shades, though distinguishable by close attention and com-
parative observation, do not admit of description and denomination, "f
This is exactly true ; but Mr. Abernethy seems to have felt that his
sentence supplied the answer to the objection against classification by
structure, which it expressed ; for as he did not, because of the inter-
mediate tints, refuse to name and arrange the primary colors, so neither
did he, nor need we, hesitate to name and classify diseases, and among
them the principal forms of tumors.
Moreover, the objection that structures may be found intermediate
l>etween those belonging to the chief forms of tumors, may be as well
made against the use of names and systems for the natural tissues.
There are no strongly outlined characters defining any of the natural
tissues that are ever imitated in tumors ; intermediate and confusing
forms are found everywhere. The various forms of fibro-cartilage, for
instance, fill up every possible gradation from cartilage to fibrous tissue :
between the looser and denser forms of connective tissue, between ten-
dons, aponeuroses, and fasciae, between epithelium and simple mem-
brane, there are, in the natural tissues, the narrowest gradations. Yet
we name and arrange the natural tissues with some truth and much
utility ; and so we may the tumors that resemble them.
Another objection against this classification of tumors is made on
the ground that there are some in which two or more different tissues
are mingled. Thus, tumors may be often found, in which fat and fibro-
* The best statement of these objections is by V<^el ; but he has well answered bis own
aignments by disregarding them in his nomenclature of tumors.
t An attempt to form a Classification of Tumors according to their Anatomical Structure.
WorkB, vol. ii, ed. 1815.
cellular tissue, or fibrous tissue and organic muscle, or cartiUgc u^
glandular tissue, or other combinations meet together. Bat,
these, some are imitations of natural combinations of tissues, u
fibrous and organic muscular tissues of the uterus arc imitated hj t^^
eo-calted fibrous tumors in its nails; and of tbe others, it need onlj ^^
remembered that such combinations do occur, and these ma; be p«s|
aside from any interference with arrangement, by making a Beriet ^
mixed tumors, or by adding to the description of each s)>cciGB tbecov^,
binations into which it may enter.
Yet another objection is made, that the characters of turoon are noc
constant, and that many must be reckoned na examples of one i^ieeie*,
which are not much, if at all, like one another.
This diversity of characters is, indeed, the great difficulty with whicl
the pathology of tumors has to contend ; but the diveraity is not w it
called inconstancy : it is due to tbe fact that each tumor has, like etdi
natural tissue, its phases of development, of degeneration, and ofdiMaM.
Now, we have scarcely yet begun the study of the variations to wbiek.
in each of these phases, the several tumors are liable. We may lii«
learned, for example, the general characters of cartilaginous tamon, it
they grow in the most favorable conditions; but how little do we knw
of the various aspects these may present when they fail of due develop-
nient, or fall in various diseases, or variously degenerate I Yet «n
these changes have to be studied in the history of every tumor; tnJil
would be as reasonable to charge any natural tissue with inconstane;,
because it is altered in development and disease, as to hold that tl#
similar diversity of tumors is an objection to their classification accord-
ing to their structure.
However, while 1 put this aside as an objection against cl&Mificatittt.
let me not be thought to underrate it as a difficulty; it is the prtl
difliculty with which we have to contend. The work we have to lioii
not only to distinguish each kind of tumor from all other kinds, biB.
and in order to this end, to distinguish, as I may any, each kind frM
itself, by learning in each all the changes occurring in the rtrioo
stages of its life. The difficulty of such a task cannot be esaggerauJ.
while we consider the rarity of the objects to be studied ; bat it mail b«
overcome before we can cease to speak of "anomalous tumorg," andif
"strange distempered masses," or, which is more Important, befort"
can, even after tbe removal of a tumor, speak with certainty of tbe iWK
of a case.
J
SIMPLE GTST8. 853
LECTURE XXIL
SIMPLE OR BARREN GTSTS.
The CygtSy or Ot/stic Tumors^ to which I shall devote this lecture and
the next, form a very numerous group, and have only or barely these
characters in common ; namely, that each of them is essentially a cyst,
sac, or bag, filled with some substance which may be regarded as en-
tirely, or for the most part, its product, whether as a secretion, or as
an endogenous growth.
We may conveniently arrange cysts under the titles "simple*' or
"barren," and "compound'* or "proliferous;" the former containing
fluid or unorganized matter, the latter containing variously organized
bodies.
Among the simple or barren cysts, we find some that contain a fluid
like that of one of the serous membranes ; such are certain mammary
cysts, and those of the choroid plexus : some are full of synovia-like
fluid, as the enlarged bursae : others are full of blood, or of colloid, or
some peculiar abnormal fluid : while others, forming the transition be-
tween the barren and the proliferous cysts, contain more highly organic
secretions, such as milk, or mucus, or salivary or seminal fluid. These
several forms we may arrange with names appropriate to their contents ;
as serous, synovial, mucous, sanguineous, colloid, (Salivary, seminal, and
others.
Among the cysts, whether barren or proliferous, it is probable that
at least three modes of origin may obtain. 1st. Some are formed by
the enlargement and fusion of the spaces or areolae in connective or
other tissues. In these spaces fluids collect and accumulate ; the tissue
becomes rarefied; and, gradually, the boundaries of the spaces are
levelled down and walled in, till a perfect sac or cyst is formed, the
'Walls of which continue to secrete. Thus are produced the bursae over
the patellae, and others ; and to this we may refer, at least in some
eases, the formation of cysts in tumors, and, perhaps, in other parts.
2dly. Some cysts are formed by dilatation and growth of natural
ducts or sacculi ; as are those sebaceous or epidermal cysts which, formed
ly enlarged hair-follicles, have permanent openings. Such, also, are
certain cysts containing milk, that are formed of enlarged portions of
lactiferous tubes ; such the ovarian cysts formed by distended and over-
sown Graafian vesicles ; and such appear to be certain cysts formed of
Elated portions of bloodvessels shut ofi* from the main streams.
Sdly. Many, and perhaps the great majority of cysts, such as those
of the kidney, the choroid plexuses, the chorion, and the thyroid gland,
are formed by the enormous growth of new-formed elementary struc-
tures having the characters of cells or nuclei, which pursue a morbid
course from their origin, or from & very early pertotl of Uictr
nient.
It might, on eome grounds, be desirahle to classify the cysla accor^
ing to their respective modes of formation ; separating the "secotidar**
cysts," as those have been called which are derived by growth or cxpu^
sion of normal parts, from the " primary," or, as they might be ollt^
the "autogenous" cysts. But at present, I believe, eueh » diviiic^
cannot ho made ; for of some cysts it is impossible to say in which n^^
thod they originate, and, in some instances, either method may lead ^
an apptirently similar result. Thus, some sebaceous or epidermal rt^n
are clearly formed of overgrown hair-folHclcs; others are of diadiifi
autogenous origin. Some ranulse are probably forme<l by dilatation «f
the submaxillary duct, obstructed by calculi or otherMisc; othen 6;
anormal development of distinct cysts, or possibly of a bursa belwm
the muscles of the tongue.* Some cysts in the mammary gland m
certainly dilated portions of ducts ; others are, from their origin, mm-
mal transformations of the elementary structures of the gland. But
in each of these cases it may be impossible, when the cyst is fiilf
formed, to decide what was its mode of origin : whether by growth at
parts once normally formed, or by transformation of elementary UJ
rudimcntal structures.
Of the three modes of the formation of cysts to which I have refenwl,
the first two, namely, that which is accomplisbcil by expansion of anoUr
spaces, and that by dilatation and growth of ducts or veaiclea, KueAj
need an explanation.
Indeed, if it were not for some convenience in surgical practio«^*<
should not retain most of the cysts thus formed, in the list of tumon:
for their growth appears, in most instances, to be due only to the tea-
mutation of the contents of the obstructed tube or eacculus, and Inbt
exactly adjusted to this accumulation, and commensurate with it. Tbu
it is in the cases of ranula with obstruction of the submaxillary <liiti
and the similar dilatations of the pancreatic duct ;t in the cystiftfB
dilatation of the obstructed Fallopian tube; in the dilated hairfollicW;
in hursie; and in some others. These are all conventionally rectoM^
among cysts and arranged with tumors : but several of the like toJ
are never so reckoned ; such as the cyst-like gall-bladder, dilated lilli
■ SeaFlcbchman.in Schmidl't Jkhrbucher, 1841, B. 39,anJ Fterichi, UeLsr GalkMiV
CoHoidgefchwillitr, GGllingen, 1847, p. 37.
t An eieelleni itiuatniion of craiiroim itilaniHin r>r iha pincrHi, ihrancfa otaWMiNl'
the duel. carnD under ihe notice of ihe edilor a aliorl lime hark, in lbs bodjr of • BNavM
died with ■ ciinovTOiis growth in the head of iba Eland. Tlie panoiru M flnl MfH*^
peared to have been convprted into a large mullilociilar cyn; bulk ofWiil aiamlB^
oonvioced bini Ihai the cyit.IIke dilalalioni were nothing more lliui Ihecapaa^a^
filled with the tomewlini thickened and r^ncenirateil tecretion of ibe (IukL TImm '*'
tatkm* alj mmmnnieaicil with each othei ihniuxh the duel, w thai when a pDMHO****
made inio one. and a plpelte inlrodiioed, all the Quid wa* drawn off. An analfril il **
(Iiiid may be found recorded in Brown-Sjquaid'g JbI. de la Phyi, April, 1801.
L
GENERAL HISTORY OF CTSTB. 855
thin mucus, when the cystic duct is completely obstructed ; the dila-
tation of the uterus, filled with serum after closure of its external
orifice ; the distended sheath of a tendon ; and others. Convenience
and common usage have decided what cysts may be grouped with those
which alone, we may anticipate, will be classed with tumors when patho-
logy becomes more accurate and strict. Convenience alone, also, decides
for the omission, from so vague a class as this, of the sacs or capsules
that are formed round foreign bodies and solid tumors, and of the sacs
that may be formed on the free surfaces of extravasated blood or in-
flammatory exudation.
For the third method of formation enumerated above, a more de-
tailed account is required ; and this I will now endeavor to give.
The general structures of the cysts thus formed may be best studied
in those that are so commonly found in the kidneys, or the mammary
or thyroid gland, or in any instance of an ordinary serous cyst. Such
a cyst, when large enough for naked-eye examination, is usually con-
structed of fine, well-formed, connective tissue, of which the filaments
are commonly mingled with nuclei, or nucleus fibres, and are variously
interwoven in a single layer, or in many that are separable. The mem-
branous walls thus formed* are, in general, rather firmly connected with
the adjacent parts, so that the cysts cannot easily be removed entire ;
and from these parts they derive the bloodvessels that usually ramify
copiously upon them. They are usually, also, lined with epithelium,
which is generally of the tessellated form, and may consist, according
to Rokitansky, of either nuclei or nucleated cells. "*"
I am not aware that minute examinations havo been made of the
modes of earliest formation of any of the cysts of this kind, that are
common subjects of surgical consideration ; but there can be little doubt
that, in their formation, they resemble the cysts of the kidney and
other internal organs. In these organs the origin and progress of cysts
liave been profoundly studied by Rokitansky ;t and I shall best describe
them by giving an abstract of some of his observations, in illustration
of a copy of one of his outline sketches of the minute structure of the
cystic disease of the kidney (Fig. 44). They confirm and greatly ex-
* Rokitansky says (Ueber die Cyste, p. 4) there is often no epithelium in the larger cysts,
«nd their "inner layer is a nucleated structureless or striated blastema, externally splitting
%nVo fibres in the direction of the long axis of the oval nuclei it contains." Epithelial cells,
apparently altered so as to resemble very large cells of inflammatory lymph, are commonly
Csand in the tenacious contents of bursas. M. Girald^s tells me that the cysts which so often
cx^enr in the antrum are commonly lined with ciliary epithelium. In other localities, also,
^jwIb hatre been observed, which possessed a more or less perfect lining of ciliated epithe-
liain. Thus Friedrich (Yirchow's Archiv, vol. xi, p. 466) describes such a cyst in the liver :
iTijcbow (tame vol., p. 469) refers to a case by Luschka, where, in the interior of an ovarian
cytt, papillary excrescences, covered by ciliated epithelium-cells, were found ; and Athol
JohnaoD (Med. Times and Gaz., Feb. 16, 1856) relates a case of fibroKsystic disease of the
testicle, socne of the cysts in which had a ciliated epithelial lining.
t Ueber die Cyste. Wien, 1850.
GENERAL I
Hi the results obtained b; the similar investigtttions of Frericlis,* and
By fully establish the accuracy of the observations on the cystic de-
generation of the
Pig. *i.
I
I
kidney, which were
made by Mr. Sim-
on,f to whom patho-
logy is indebted for
the first ^ure step in
this rich path of in-
quiry. They may be
repeated in almost
any portion of a gra-
nular kidney con-
taining cysle, or in >
choroid plexus with
cysts : but, I believe,
the process may b«
best traced in the
cystic disease of the
embryonic choriou,
the hydatid mole, as
it has been called. | To this I shall again refer in the next lecture.
In a portion of a granular and cystic kidney, nests, as Rokitanaky
calls them, of delicate vesicles, from a size Just visible to that of a millet
seed, may be seen imbedded in a reddish-gray or whitish substance.
These differ in size alone from the larger cysts to which one's attention
would be sooner attracted ; and, on the other side, it is only in size that
they differ from many much smaller. For if a portion of such a nest be
examined with the microscope, one finds, together with the debris of
the kidney, variously diseased it may be, a vast number of vesicles or
cysts that were invisible to the naked eye.
The most striking of these have a wall consisting of layers of fibres— i
scattered over with curved nuclei (a), and are filled with granulate<^l
nuclei, or, more rarely, with round or polyhedral cells, some of whiclr=:
may contain a molecular or granular pigmental matter (<?). In man^~-
of these cysts, the nuclei or cells are reduced to an epithelial lining c=^
the cyst ; and in some even this is absent, and the " barren" cyst ^^^
filled with a clear or opaline adhesive fluid.
From the size just visible to the naked eye, such cysts vary to ij, -*i
of an inch in diameter ; and, together with these, are cysts whose w^l7«
(though their contents are like those of the others) consist of a strOc-
tureless hyaline membrane : and these lie in a stroma which is eqnn llj
* Usbec Ga[1ert-oder ColloiilgeichwalME.
t On Subacute InBammalion oflhe Kiilney, in Ihe Mediuo-ChimrKicnL TrBntoclions, ml.
XX. See 8)N) Dr. Gairdner on Cy»i FDrmaiions in KiJney, Edin. Med. Jul.. tSS3.
I Meltenlieimer, in MUller
I
GENERAL HISTORY OF CYSTS. 857
simple^ but seems to develop itself gradually into a fibrous structure
drcumscribiug the cysts.
Moreover, one finds, in the same specimens (as in the lower part of
Fig. 44), structures of the most varied sizes, which, except in size, agree
completely with the last-mentioned simple and structureless vesicles,
and show every grade of size down to that which is just larger than a
nucleus. The smallest of these contain a clear fluid, or are slightly
granulated : in the larger there is a central nucleus, and to this are
added a second, a third, and a fourth nucleus, and so on till there
appear several, which fill up the commensurately enlarged vesicle
(«, «, Cj &c.). Now, in such a nucleus seems to lie the nucleus of the
history of development of those autogenous cysts, not in the kidney
alone, but in any part in which they may occur. A nucleus grows to
be a cyst, whether a simple or barren one, or one that has an endoge-
nous production of nuclei, or cells, or any other structures.
It would be tedious now to trace, from this general sketch of their
origin, all the phases through which such cysts may pass. Rokitansky
has done it amply. We have here the elementary constituents. But
the simple cyst-wall is capable, not only of growing, but of acquiring,
the laminar and nucleated fibrous tissue which we find in its full estate ;
acquiring these, we may presume, just as more normally, the simple
membranous wall of a new bloodvessel acquires, as it grows, the nuclei
and fibrous tissue that belong to its more perfect state. Such might be
the least abnormal course of any cyst ; but from this it may deviate ;
thickening, acquiring continually new layers, calcifying, and in other
ways showing the signs of degeneration or disease. The contents,
also, of the cyst may assume even yet more various forms : to name
only the extremes, — they may retain the simple state of liquid ; or with
liquid there may be a simple, or a specially secreting, epithelial layer ;
or, a series of successively ihclosed nuclei or cells may be formed within
that which first enlarges ; or, the contents may acquire the structure of
well-organized glands, or of cancer, or some other tissue ; and between
these extremes, according to conditions which we have no power to trace
or explain, they may pass in any of the manifold ways of wrong, the
ends of which I shall have to describe.'*'
* In the small cysts containing a gelatinous-looking or honey-like substance, which not
onfreqaPDtly occur in the ovary, the editor has more than once, on making microscopic ex-
aminatioo, found the yellow mass for the most part composed of pale nucleated cells, some
of which were little larger than a human white blood corpuscle, others were several times
at large, and others again were intermediate in size. In these larger cells many nuclei, evi-
denxly the products of endogenous development, were seen, from which circumstance they
were more opaque than the smaller cells. Mr. Goodsir has described and figured (Anat. and
Path. Obf«., p. 107, pi. 1, figs. 1, 2, 3, 1845) numerous nucleated cells from the honey-like con-
tents of a cyst removed from beneath the tongue. Inside many of these cells, nuclei in
Tarkme stages of development were seen, and in these cases the cells were more opaque,
'and distended beyond the average size. By the multiplication of the nuclei in the interior
of these cells the reproduction of new cells was produced.
858 GBNBRAL HISTORY OF CYSTS.
Important as the history of cysts may be in its direct bearings, yet
these are not all that Tve may observe in it. In their history I cannot
but think we may discern an image of the first form and early progress
of many innocent solid tumors also. For, as the cyst is traced from
the mere nucleus, onwards to its extreme size or complexity of struc-
ture or contents, so, it is very probable, from the numerous correspon-
dences between them, that these solid tumors also have a similar begin-
ning in some detached element, or tissue-germ, or in some group of
such germs, which, in their development, multiplication, and growth,
may coalesce, and then may appropriate, or exclude for absorption, the
intervening substance.
Thus, in the form of erring nuclei, we may, I think, almost appre-
hend the structural origin of these cysts and tumors ; yet, if we may,
the question still remains whether the elementary structures in which
they begin, be some new and special morbid elements, or some natural
rudimental structures perverted from their normal course. Mr. Simon,
speaking of the cysts of the kidney, regards them as " vesicular trans-
formations of the ultimate structure of the gland ;** and to this view,
without adopting some ingenious suppositions which he has connected
with it, I would adhere. For, unless a cyst or a solid tumor (assuming
this mode of their origin to be correct) were really a transformation of
a nucleus, or a cell, of the part in which it grows, we could not under-
stand the v^ry general similarity that we find between the contents of
certain cysts, and the secretions or structures of the glands in or near
which they occur; nor yet the likeness which commonly exists between
the solid tumor and the tissue in which it is imbedded. These things
are as if the first beginning of the abnormal growth were in some de-
tached element of the natural tissue, which element, being perverted
from its normal course, thenceforward multiplies and grows, conforming
with the type in minute structure and composition, but more and mor
widely deviating from it in shape and size.*
Such are the facts, and such the speculations that we may entertain
respecting the origin, or, at least, the smallest visible beginning, of
cyst or an innocent solid tumor. Need I add that if even this be tru
we are yet far from the explanation of the cardinal point in the path
♦ The doctrine of the continuous development of texture — of the descent of cells and t — mu
clei from pre-existing cells and nuclei— bears out the opinion expressed in the text. It -^j.
plains how, by an irregularity in the development of the cells and nuclei of a part, tun* ^j/j
may arise in many of the textures corresponding in structure to the tissues in which tYjer
take their origin. How fibrous tumors spring from periosteum and other forms of connec-
tive tissue; adipose and fibro-cellular tumors in the subcutaneous or submiKJOUs areolar tis.
sue ; cartilaginous, myeloid, and osseous tumors in connection with bone ; glandular tumors
with glands, &c. The intimate structural relations of the adipose and connective tissue*, the
close morphological relations which have of late been shown to exist between conoectire
tissue, bone and cartilage— that the connectivetissue-corpuscles, bonecorpuscles, and cam-
lage-cells, are strictly homologous parts— also serve to explain the occasional origin in the
connective tissue of fatty tumors, and of growths, in the formation of which, bone and cirti.
lage take an important share.
GASEOUS AND SEROUS CYSTS. 859
logy of tumors, — ^their continual growing. Why should these detached
tissue-germs, or any less minute and less isolated portion of an organ,
grow, while all other germs and parts that are most like them remain
unchanged ? I have already confessed my ignorance.
I will endeavor now to illustrate the histories of particular forms of
the simple or barren cysts.
1. The first that may be enumerated are Gaseous Otsts. I know,
indeed, concerning them only the specimens placed by Hunter in his
Museum ;* but these should be admired, or almost venerated ; for their
histories include the honorable names of Hunter, of Jenner, and of
Cavendish. Mr. Hunter says of them, — " I have a piece of the intes-
tine of a hog, which has a number of air-bladders in it." ... '^ It was
sent to me by my friend Mr. Jenner, surgeon, at Berkley, who informed
me that this appearance is found very frequently upon the intestines of
hogs that are killed in the summer months." . . . ^^ Mr. Cavendish
was so kind as to examine a little of this air ; and he found ' it con-
tained a little fixed air, and the remainder, not at all inflammable, and
almost completely phlogisticated.' "f
What a relic have we here ! Surely, never, on an object so mean to
common apprehensions, did such rays of intellectual light converge, as on
these to which were addressed the frequent and inquiring observations
of Jenner, the keen analysis by Cavendish, and the vast comparison and
deep reflection of John Hunter ! Surely, never were the elements of
an inductive process combined in such perfection ! Jenner to observe ;
Cavendish to analyze ; Hunter to compare and to reflect.
2. The Serous Cysts, or Hygromata, are, of all the order, the most
abundant. The term includes nearly all such as have thinly liquid, or
honey-like contents, of yellow, brown, or other tint. Their most fre-
quent seats are, by a hundred-fold majority, in or near the secreting
glands or membranes, or the so-called vascular glands ; but there is
scarcely a part in which they may not be found. Their frequency in
connection with secreting structures has led some to hold that they are
all examples of perverted epithelial or gland-cells : but their occurrence
in such parts as bones and nerves, among deep-seated muscles, and in
fibrous tumors, makes it sure that they may originate independently of
gland-cells ;| though why any element of a solid tissue should retain
* MusmiRi of the Coll. of Surg., No. 153-4.
f See Hanter's Works, vol. iv, p. 98, and Description of PI. xxxvlL
X Some Tery interesting specimens of serous cysts in bones are in the Museum of St.
Geoige't Hoepital. They are described by Mr. CsBsar Hawkins, in his Lectures on Tumors,
in the Medical Gazette, vols, xxi, xxii ; and in a Clinical Lecture in the same, vol. xxv, p.
472. See also, a remarkable case by Vanzetti, in Schuh (Pseudo-plasmen, 175). There are
tome remarkable specimens of cysts in the antrum, in the Museum of St. Thomas's Hospital,
prepared by Mr. Wm. Adams, who showed them to me. M. Giraldds considers all such as
360 SBROUS CTSTS.
the vesicular form which it has in its germ state, and in that form grow,
we cannot tell.
Of this numerous group of serous cysts, however, I will speak at
present of only such as may best illustrate their general pathology,
and are of the most importance in surgical practice ; and I will, to these
ends, refer chiefly to the cysts in the neck, the mammary gland, and
the gums.
Single serous cysts in the neck form what have been called " hydro-
celes of the neck,'* and are well exemplified by a specimen in the Mu-
seum of the College.* This is a single oval cyst, with thin, flaccid,
membranous walls, which even now, after shrinking, measures more
than six inches in its chief diameter. It was successfully removed by
Mr. Thomas Blizard from between the platysma and sterno-mastoid
muscles : and a part of it is said to have passed behind the clavicle. It
was filled with a clear brownish fluid.
Such cysts, but various in size and other characters, are more apt to
occur in the neck than in any other part of the body. Many are single
cysts like this ; but others are complex, having many cavities, whether
separate or communicating ; and some consist of very numerous cysts,
even of hundreds, clustered in one comparatively firm mass.
In situation, too, they are various. In some cases they lie in the
front of the neck ; in others, at one or both sides : they may lie by the
lower jaw, over the parotid, by the clavicle, or anywhere or everywhere
in the mid-spaces. And in any of these situations they may extend
very deeply among the structures of the neck, and may adhere to them
so closely, and may so thinly cover them, as scarcely to conceal them
when laid open. Their date of origin is often obscure. In many, per-
haps in the majority of cases, they appear to be congenital ;t but they
may be first observed at any later period of life. Last year Mr. Law-
these to be formed by cystic disease of the gland-structures, discovered by him in the mucoos
membrane of the antrum. His description of the normal anatomy of the mucous membrane
of the antrum, and of the mode of formation of the cysts in that locality, is in the Memoir^
de la Societe de Chirurgerie de Paris, 1853, and in a separate essay, " Recherches sur les
Kystes Muqueux des sinus Maxillaire," Paris, 1860.
♦ Mus. Coll. Surg. 146. Many well-marked examples of the disease in all its forms
are recorded by Dr. OBeirne (Dublin Jour, of Med. and Chem. So. vol. vi, p. 834) ; Mr.
Lawrence (Med.-Chir. Trans, vol. xvii, p. 44) ; Mr. Csesar Hawkins (Med.-Chir. Trao».TOL
xxii, p. 231) ; Mr. Liston (Practical Surgery, p. 330, ed. 1840) ; and others. A monograph
by Wernher (Die angeborenen Cysten-Hygrome, Giessen, 1843) is referred to by Bruch,!.
c, but Lhave not been able to see it.
t The essay by Wernher, referred to in the foot-note above, probably includes all the
cases of congenital serous cysts in the neck at that time recorded (1843). Since then,
Gilles (De Hygromatis Cysticis Congenitis, BonnjF, 1852) has added three. But these were
complex tumors, formed of cysts, adipose and fibrous tissues, bone, and one even contained
a tooth. These growths, therefore, must be distinguished from simple cysts. They are,
probably, of the nature of monstrosities by excess, and are allied to those congenital cjrsts
which are occasionally found connected with the sacrum and coccyx, and of which a very
interesting account, by Prof Simpson, rftay be found in the Med. Times and Gazette, July
2, 1859. Also by Dr. Glaser in Virchow's Archiv, 1858, p. 187.
SEROUS CTSTS. 861
rence removed a collection of four large cysts from oyer the parotid
gland and mastoid region of a man, twenty-eight years old, who had
observed their beginning only seven years previously. Three of these
were filled with serum, and one with pus.
Of course, in such a variety of forms, there must be more than one
kind, in the group of cysts that are thus, for mere convenience, placed
together. The variety of origins, indeed, to which cysts in the neck
may be traced, gives them peculiar interest in relation to the general
pathology of cysts.
Some are evidently connected with the thyroid gland ; though, being
singly developed, and growing to a very large size, their relation to it
may be at length obscured, and they may appear, during life, quite
isolated. A woman, forty-eight years old, was under Mr. Vincent's
care, in St. Bartholomew's Hospital, in July, 1841, with a tumor in the
front of her neck as large as the head of a child two years old. The
tumor contained fluid, which was twice withdrawn with a trocar. At
the first time the fluid looked like serum, but coagulated spontaneously ;
at the second, it was mixed with blood. After the second operation
the cyst inflamed and discharged grumous and sanious pus ; but it also
enlarged quickly, and the patient died unexpectedly, and rather sud-
denly, suffocated.
The preparation* displays a cyst occupying nearly the whole right
lobe of the thyroid gland : its walls are nearly two lines in thickness ;
its cavity was full of lymph, pus, and blood ; and the sudden death was
due to a discharge of a great part of its contents into the pharynx and
larynx, through an ulcerated aperture into the former.
Besides these cysts which lie within the thyroid gland, some that lie
near to it are very probably of the same nature ; cysts formed in some
outlying portion of the gland, such as I referred to in the last lecture.
But of this mode of origin we can scarcely have a proof when the cyst
is fully formed and largely grown.
Other of these cysts in the neck appear to be transformations of vas-
cular tumors ; i. e. of erectile vascular growths or naevi. I shall refer
to this point again : it is made probable by the close connection which
some of these cysts have with large deep-seated veins ; by the occa-
sional opening of bloodvessels into their cavities ; and by their some-
times distinctly forming portions of vascular naevi. A girl, three and
a half years old, was under Mr. Lawrence's care, in 1849, in St. Bar-
tholomew's Hospital, with a large soft and obscurely fluctuating tumor
covering the greater part of the left side of the neck, and the lower
part of the cheek. Such a swelling had existed from birth, but it had
of late enlarged very much. It was composed of a cluster of close-set
cysts, containing spontaneously coagulable fluid ; but at its upper part
a firmer portion of its mass consisted of a collection of tortuous and
* Museum of St Bartholomew's Hospital, Ser. xxii, No. 16.
«i4
862 SEROUS CYSTS.
m
dilated bloodvessels like those of a nsevus. The examination made of
it, by Mr. Coote,* after its removal, was such as to leave little doubt
in his mind that it had origin in or with a naevous growth : and other
cases, to which I shall refer in speaking of erectile tumors, have con-
firmed this view, especially some of those which are published by Mr.
Hawkins.
But when we have separated all the serous cysts in the neck that
may be referred to these two sources, there will probably still remain
many that we can assign to no such mode of origin, and which at
present we must class among primary or autogenous cysts, independent
of any secreting structure.
Among these are some with fluid contents of peculiar viscidity, ropy,
or honey-like, and deriving a peculiar aspect from including al)undant
crystals of cholesterine. Such contents may occur, perhaps, in any
cyst in the neck or elsewhere ; but they appear to be comparatively
frequent at or near the front of the larynx. In the College Museum
there is such a cyst,t attached to the hyoid bone of a sailor, who was
between fifty and sixty years old, and in whom it had existed nearly
as long as he could remember. It contained a brownish-yellow, grum-
ous, honey-like fluid, with abundant crystals of cholesterine.
In 1849, Mr. Lawrence had, at St. Bartholomew's Hospital, a
patient, thirty-five years old, on the left side of whose neck, directly
over and closely attached to the thyro-hyoid membrane, was a smooth
oval tumor, about an inch in length. He had observed a regular in-
crease of this tumor for five or six years; but its bulk and deformity
alone were inconvenient. Mr. Lawrence freely cut into it, and let out
a thick honey-like fluid, in which large groups of crystals of choleste-
rine were visible even with the naked eye. The cyst, after the incision,
suppurated, and then the wound healed, and the patient left the hospital
quite well : but I have lately seen him with an appearance as if some
remains of the cyst were again filling.
Cysts like the last-described are not uncommon in or near the gums,
lying usually behind the reflection of the mucous membrane from the
gum to the cheek. Their occasional large size, and their thick tough
walls obscuring the sense of fluctuation, may make them at first look
formidable. A woman, thirty-eight years old, was under my care in
1849, in whom, at first sight, I could not but suppose something was
distending the antrum, so closely was the deformity of the face due to
such diseases imitated. But the swelling was soft and elastic, and pro-
jected the thin mucous membrane of the gum of the upper jaw, like a
half-empty sac. I cut into the sac, and let out nearly an ounce of
* Lecture by Mr. Lawrence, in the Medical Times, November 30, 1850.
f Mils. Coll. Surg., 148. These, 1 presume, are examples of Meliceris. The cysts
which Mciller describes under the name of cholesteatoma are quite different from these, and
will be noticed with the cutaneous cysts in the next lecture.
SEROUS GTSTS. 368
turbid browDish fluid, sparkling with crystals of cholesterine. The
posterior wall of the cyst rested in a deep excavation on the surface of
the alveolar border of the upper jaw ; an adaptation of shape attained,
I suppose, as the result of the long-continued pressure of the cyst,
which had existed six years.
At nearly the same time a young man w^as under my care with a
similar swelling of larger size, which he ascribed to an injury of the
gum or alyeolar border of the upper jaw only six months previously.
In neither of the cases could I find any disease of the maxillary bone;
but it sometimes exists in intimate connection with these cysts, and
sometimes the fang or socket of the nearest tooth is diseased. I lately
saw a lady in whom a small cyst of this kind had existed twenty-seven
years, almost daily discharging and refilling. It had its origin in a
blow by which the two median upper incisors were loosened. One of
them was again firmly fixed ; the other had remained slightly loose,
and its crown was dark.
In no organ is the formation of cysts more important than in the
mammary gland. Every variety of them may be found here : but I
will speak at present of only the serous cysts.
Some of these cysts are dilated ducts, or portions of ducts grown into
the cyst-form. During lactation, cysts thus derived may be filled with
milk, and may attain an enormous size, so as to hold, for example, a
pint or more of milk.* In other cases they may contain the remains
of milk, as fatty matter, epithelial scales, &c. ; or they may be filled
with transparent watery fluid, without coagulable matter ;t but much
more commonly they contain serous fluid, pure, or variously tinged with
blood, or its altered coloring matter, or various green, or brown, or
nearly black fluids.^
The complete proof of the origin of some of these cysts as dilated
portions of ducts is, that by pressure they may be emptied through the
nipple, or that bristles may be passed into them from the orifices of
tubes. But although these facts may be often observed, yet I agree
with Mr. Birkett in thinking that the majority of cysts in the mammary
gland are formed in the manner of the renal cysts, to which, indeed,
they present many points of resemblance.
The most notable instances of mammary cysts are those in which
the whole of the gland is found beset with them. This may occur
while the proper substance of the gland appears quite healthy ; § but I
* See a case by M. Jobert de Lamballe, in the Med. Times, January 4, 1 1, 184«'3 ; and a
collection of cases by Mr. Birkett, in one of which ten pints of milk were evacuated (Dis-
eases of the Breast, p. 201).
f Brodje, Lectures on Pathology and Surgery, p. 1 55.
X Their various contents are well shown in Cooper's Illustrations of Diseases of the
Breast, pi. i ; and a full account of all the diseases of this class is given by Mr. Birkett in
bis work already cited.
5 Two such cases are described by Sir B. C. Brodie (Lectures on Pathology and Surgery,
p. 139).
364 SEROUS CYSTS.
think it is more commonlj concurrent with a contracted and partially
indurated state of the gland ; a state which, independent of the cysts,
appears similar to cirrhosis of the liyer, and has, I think, been named
cirrhosis of the mammary gland. Its coincidence with cysts proves its
nearer relation to that shrivelled and contracted state of the granular
kidney with which the renal cysts are so commonly connected; or (when
the cysts are formed by partial dilatation of the ducts), to the shrivelled,
indurated state of the lung that may coincide with dilatation of the
bronchi.
The cysts in these cases are usually of small size, thin-walled, full
of yellow, brown, green, and variously deep-colored fluids ; fluids that
are usually turbid, various in tinge and density, but not usually much
denser than serum. They do not lie in groups, but are scattered
through, it may be, the whole extent of the gland ; and their walls,
though thin, are tough and tense, and very closely adherent to the sur-
rounding gland-substance. Similar small cysts are sometimes found in
connection with hard cancer of the breast ; and in this case they have
been called by Mr. Hunter and others *' cancerous hydatids ;*' but their
proper relation in such cases appears to be, not with the cancer, but
with the coincidently shrivelled gland.
In this disease of the mammary gland there is no reason to believe
a malignant nature, though the coincidence with cancer appears not
rare. Yet the diagnosis between it and cancer is not always clear, and
many breasts have been removed in this uncertainty. I once saw such
a case, and it ended fatally. A woman, fifty years old, had, in her left
breast, just below the surface of the mammary gland, a small, smooth,
oval, and movable tumor. It felt firm, but not hard ; but, external to
it, in a line extending towards the axilla, were two or three small round—
'* knots,'* scarcely so large as peas, and quite hard. In the axilla was^*
an enlarged gland. The breast was soft, flaccid, and pendulous. Th^
tumor was sometimes painful, and a serous and bloody fluid often flowe(&
from the nipple. The patient's youngest child was sixteen years old,
and the tumor had been noticed six months, having arisen without evi-
dent cause. There was doubt enough about the diagnosis of this case
to suggest that the tumor should first be cut into. An incision exposed
the cavity of a cyst full of dark, turbid, greenish fluid, and near it
many more cysts. Similar cysts pervaded the whole extent of the
gland, and the whole breast was therefore removed. Many of the cysts
communicated with lactiferous tubes, from which bristles could be passed
through the nipple.*
In this case one comparatively large cyst existed, with many of much
smaller size. In more usual cases one cyst has a yet greater predomi-
nance over others, or even exists alone. Sometimes, in such instances,
* In the Museum of the Middlesex Hospital is a breast from a woman in whom both
mammary glands were thus diseased. In the College Museum, Nos. 150 and 152 best illus-
trate the disease.
SYNOVIAL CYSTS. 365
the removal or laying open of one large cyst has been sufficient ; but in
some, smaller cysts neglected have enlarged, and the disease has ap-
peared to recur.*
The single cysts of the mammary gland may become enormous. I
know not what boundary may be set to their possible size ; but I find
one case in which nine pounds of limpid "serosity** were produced in
three months in the breast of a woman thirty years old.f In this case
the walla of the cyst were thin, and the fluid serous ; and the fact
illustrates a general rule, that the cysts which contain the simplest
fluids, and which have the simplest walls, are apt to grow to the largest
size : thickening of cyst-walls, and, much more, their calcification,^
are here, as elsewhere, signs of degeneracy, and of loss of productive
power.
It would appear as if any cyst of the mammary gland might, after
some time of existence in the barren state, become prolific, and bear
on its inner surface growths of glandular or other tissue. But of these
proliferous cysts I will speak in the next lecture. §
3. Of Synovial Cysts I need say very little. Under the name may
be included all the anormal bursse, or ganglions, as they are called. In
these, again, two methods of formation probably obtain. Some, of
which the best example is the bursa over the patella and its ligament,
are merely enlargements, with various transformations, of bursse natur-
ally existing. Not materially different from these are the bursae which
form anew in parts subjected to occasional localized pressure, and which
appear to rise, essentially, from the widening of spaces in the areolar
form of connective tissue, and the subsequent leveUing or smoothing pf
the boundaries of these spaces. But others, such as the bursae or gan-
glions which form about the sheaths of the tendons at the wrist, appear
to be the cystic transformations of the cells inclosed in the fringe-like
processes of the synovial membrane of the sheaths. The opportunities
of dissecting these are rare ; but I believe there is a close resemblance,
in mode of formation, between them and the cysts of the choroid plexus.
* Sir B. C. Brodie, loc. cit. p. 146, note.
'\ Case by M. Marini, cited by M. B^rard, " Diagnostic diff($rentiel des Tumeurs du
Sein,'' p. 86.
X For a case in which the walls of a cyst in the breast were calcified, and crackled like
those of ossified arteries, when pressed, see Berard, loc. ciu p. 56 j and for a similar calca-
reous degeneration of the wall of an ovarian cyst, reference may be made to a case of
separated and transplanted ovary, recorded by the editor in the Ed Med. Jal., Feb. 1861.
5 Having in view only the illustration of the more general pathology of these cysts, I have
not referred to raore special instances of them. Examples enough are to be found in all the
works here quoted. Neither have 1 mentioned any analysis of the contents of serous cysts ]
for few haye been made, and these few were made on such various materials, that no
general account of them can be rendered. Several are cited in Simon's Medical Chemistry ;
and ID Frericbs' Ueber Gallert- oder Colloidgeschwiilste, pp. 7-9, &c. ; and by Virchow, in
the VerhandluDgen der med.-phys. Gessellsch. in Wiirzburg, B. ii, p. 281. See also, on the
coDteDia of OTarian cysts, Dr. Tilt's papers in the Lancet^ June, 1850.
366 MUCOUS CYSTS.
Rokitansky has shown that these are due to cystic growth in the villi
appended to the margins of the plexus, which yilli are very similar, in
their constituent structures, to the processes of the synovial fringes.
And the probability of similar origin is enhanced by the likeness of the
contents of the cysts, in both cases, to the fluids secreted by the fringes
in the normal state.*
4. Under the name of Mucous Cysts we may include all such as are
formed in connection with simple mucous membranes, or with glandular
structures which we call mucous, while we know no other or peculiar
office served by their secretions.
There may be many cysts of this kind ; but the best examples appear
to be those that may be named Nabothian and Cowperian cysts. The
former probably originate in cystic degeneration of the glands of the
mucous membrane about the cervix uteri. Protruding, either alone, or
with polypoid outgrowths of the mucous membrane, they are observed
successively enlarging, then bursting and discharging their mucous
contents, and then replaced by others following the same morbid course.
Or, instead of clusters of such cysts, one alone of larger size and
simpler structure may be found, f
The Cowperian cysts appear to be connected with the Cowper's,
Bartholin's or Duverney's glands in the female. Whether arising from
dilatation of the duct, or from cystic transformation of the elementary
structures of the gland, cannot be yet stated ; but, in the exact posi-
tion of the Bartholin's gland, and projecting into the vagina near its
orifice, a cyst is often found, of regular oval shape, thin- walled, of un-
certain size, but gr(Jwing sometimes to the capacity of a pint. Com-
monly the contents of such a cyst are a colorless, pellucid, or opaline
ropy fluid, like that found in the closed-up gall-bladder. But from
this they often vary. I have seen the contents of such cysts like the
ink of the cuttle-fish, like the fluid of melanotic tumors, and like thick
turbid coffee ; or, to the sight, they may exactly resemble fluid faecal
matter. J Moreover, these cysts are very apt to inflame and suppurate.
Many abscesses projecting into the vagina have in these their origin;
and the treatment these abscesses receive, by free incision, is, I believe,
appropriate for the cysts under all conditions.
It is not apparent upon what the varieties in the contents of these
* In a communication in the M6m. tie TAcad. de Med. t. xvi, 1S52, M. Gosselin has
described (in addition to the distension of the sheaths of the tendons by increased secretion
of synovia), the formation of " ganglions" by the dilatation after obstruction of the mouths of
follicles, which normally open into the cavity of the joint. The ganglions are therefore in
such cases subsynovial cysts. For an account of the loose bodies which form in these cysiSi
a paper by Lebert in the C. R. de la Soc. de Biologie, t. iv, p. 89, may be referred to.
t A remarkable example of a cyst, thus, I suppose, originating, is in the Museum of the
Middlesex Hospital.
X As in a case related by Mr. Coesar Hawkins in his Lectures, Medical Gazette, vol. xxi;
and in two cases by Lebert, Abhandluugen, p. 109.
SANGUINEOUS CYSTS. 867
cysts depend. The only instances that I could minutely examine were
the two following : In the first, a woman, 25 years old, under the care
of Dr. West, had a smooth oval swelling in the lower and fore part of
the right labium, projecting on its inner surface, and nearly an inch in
diameter. This had been observed slowly increasing for six years, and
had commenced three months after parturition. It was not painful. I
punctured it, and let out about three drachms of pellucid fluid, like
mucus, or the white of egg. The cyst had a polished white internal
surface, and the fluid contained numerous corpuscles, like very large
white blood-corpuscles, and like such as are commonly found in the
tenacious fluid of bursse. The cyst closed on the healing of the wound :
but two years afterwards either it, or some other part of the gland simi-
larly diseased, appeared again.
In the other case, the patient was forty-five years old, and under the
care of Mr. Stanley. The tumor was nearly regularly oval, occupying
the whole length of the right labium, and obstructing the vagina. She
had observed it increasing for four years : it was painless, but had been
often struck. A free incision gave issue to about fourteen ounces of
thick, inodorous, dark brown fluid, like turbid coffee. The walls of the
cyst were about one-third of a line thick, tough, compact, and closely
connected with the surrounding tissues. Mr. Abernethy Kingdon,
who examined the contents, found abundant molecular matter, and gra-
nule-masses, together with groups of cells, apparently resembling epithe-
lial cells of various sizes.
5. The Sanguineous Cysts, or cysts containing blood, are probably,
in many instances, very nearly related to the serous. Some may be
explained by an accidental hemorrhage into the cavity of a serous cyst ;
an event corresponding with the transformation of a common hydrocele
into an hsematocele. The contents of some of these cysts are, indeed,
just like those of an hsematocele, with fluid and coagulated and variously
decolorized blood. "*" But some cysts appear, from their origin, to con-
tain blood; and this blood, I think, always remains fluid till it is let out,
while that which collects by hemorrhage into a serous cyst is generally
partially or wholly coagulated. Some of these cysts with blood are
found in the same positions and circumstances as the serous. Thus, in
the neck, a series of cases of blood-cysts might be collected, exactly
corresponding with the serous cysts in that part, and, like them, pro-
bably derived from various origins, some lying in the thyroid gland,
some near it, some traceable to connection with vascular nsevi, some of
proper origin.
Of the last class one appeared to be, which was in St. Bartholomew's
Hospital several years ago. A lad, about sixteen years old, was under
* Such hemorrhages are frequent in cysts of the thyroid gland (Frerichs ; Rokitansky ;
Mnsemu of the College of Surgeons, 1502). Thus also, we may explain the hematoceles
of the tpennmtic cord, as in Mus. Coll. Surg. 2460 ; and Mus. Bartholomew's, Ser. xxviii, 11
368 • SANGUINEOUS CYSTS.
Mr. Stanley's care, with a large oval, and somewhat pendulous swell-
ing in the left side of the neck, which had existed many years, and
appeared merely subcutaneous. It was punctured, and about sixteen
ounces of fluid blood escaped, which soon coagulated. After this the
cyst closed ; a result more favorable than may generally be anticipated
from such simple treatment : for usually these, like other cysts, are not
obliterated unless after free incision.
In the parotid gland, also, cysts containing fluid blood have peculiar
interest. In 1848, I assisted Mr. Stanley in the removal of one which
lay quite within the parotid of a gentleman about 40 years old. It had
been for some years increasing in size, and lay beneath some branches
of the facial nerve, from which the need of separating it without injury
made its removal very diflScult. This, however, was safely accomplished,
and the patient remains well.
At nearly the same time, a man, 25 years old, was under my care
with a similar cyst, which had been increasing without pain for two
years. It lay in the parotid, but very near its surface. I punctured
it, and evacuated two or three drachms of bloody-looking fluid, with
some grumous and flocculent paler substance intermingled. This fluid
coagulated like blood, and contained blood-cells, much free granular
matter, crystals of cholesterine, and what appeared to be white corpus-
cles of blood acquiring the character of granule-cells. The cyst fill
again with similar fluid after being thus evacuated : I therefore dis —
sected it from the parotid gland, and the patient recovered.
Occasionally one meets with sanguineous cysts, which derive a pec
liar aspect from a columnar or fasciculated structure of their interio
making them look like the right auricle of a heart. This was sing
larly the case in one which I assisted Mr. Macilwain, in removing fro
over the lower angle of the scapula of a lad fifteen years old. It h
existed more than eight years, and grew rapidly, while, in the last ye
he was actively at work. It was now also painful. It felt like a fat
tumor, but proved to be a cyst thus fasciculated like an auricle, wit
finely polished internal surface, and containing about an ounce and a
half of liquid blood. Its walls were from one to two lines in thickne ^5,
and seemed in great part made up of small cells, such as one sees ii^ a
bronchocele, full of serous and bloody fluids. No trouble followed "fc he
operation, and the patient remains well twelve years after it.*
A cyst presenting the same peculiarity of internal surface was re-
moved by Mr. Stanley, in October, 1848, from over the pubes of a "boj
thirteen years old. It was observed increasing for nine months, anrf
part of it, consisting of a simple thin-walled serous cyst, was transpa-
rent; but behind, and projecting into this, was a more thickly-walled
cyst, containing about a drachm of dark liquid blood, and on its surface
fasciculate and polished like an auricle. Its walls were well defined,
* The cyst is in the Museum of St. Bartholomew's, Ser. xxxv, 38.
COLLOID CYSTS. 869
formed of connectiye tissue imperfectly filamentons and nncleated, and
I could find no epithelium lining it. The operation was successful.
It is not improbable, I think, that both these cases may have had
their origin in vascular naevi, like other cysts containing blood, to which
I shall refer in speaking of erectile tumors. I will now only refer to
certain cysts which, without any erectile formation, appear to be de-
rived from portions of veins dilated, and obstructed, and shut off from
the stream of blood. Such a one was removed by Mr. Lloyd, many
years ago, from a man's thigh. It lay in the course of the saphena
vein ; but neither that, nor any other considerable vein, was divided in
the operation, or could be traced into the cyst. This cyst* was of
spherical form, about an inch and a half in diameter, closed on all
sides ; its walls were tough, and polished on their inner surface : it was
full of dark fluid blood, and its venous character was manifested by two
valves, like those of veins, placed on its inner surface. On one of
these a soft lobed mass, like an intra-cystic growth, is seated.f
6. Cysts containing oil or fatty matter, without any more highly
organized substance, are very rare. Many contain fatty matters min-
gled with serous, epithelial, and other substances ; but in these the fatty
constituent is probably the result of the degeneration of the other con-
tents. Some, however, appear to contain fatty matter alone. Mr. Hun-
ter preserved a specimenj of what he marked as " oil from an adipose
encysted tumor." It was taken, I believe, from a cyst that grew "be-
tween the bony orbit and the upper eyelid ** of a young gentleman.
When recent, it was described as " pure oil, perfectly clear and sweet,
which burnt with a very clear light, and did not mix with aqueous
fluids, and, when exposed to cold, became as solid as the human fat."
In 1860 Mr. Wormald removed a small cyst from a woman's breast,
the contents of which appeared to be pure oily matter, that congealed
into a substance like lard, and contained crystals of margarine, but no
organized corpuscles. The patient remains well. Schuh§ relates two
cases of cysts under the brow, which contained similar oily matter, and
whose walls had all the structures of skin, with implanted hairs.
7. Colloid Cysts are, at present, a very ill-defined group ; the term
"colloid" being used by Frerich8,|| and other recent German writers,
for all those morbid materials that are pellucid, jelly-like, fiickering,
half solid, or more or less closely resembling the material found in gela-
tiniform, alveolar, or colloid cancer. Such a material is common in
* Moseam of St Bartholomew's Hospital, Appendix, 10.
f In the Mufleum of King's College is a large cyst removed from a thigh, into which it is
laid the saphena vein opened.
X Mas. Coll. Surg., 181 : Pathological Catalogue, vol. iv, p. 177.
5 Ueber . . . Pseudoplasmen, p. 144.
I Ueber Gallert- oder ColloidgeschwQlste.
370 SEMINAL CYSTS.
the cysts of bronchoceles, and in those of the kidney ; especially, I
think, in those which are not associated with contraction of the renal
substance, and which Baillic, and other writers of his time, described
as hydatid disease of the kidney.
The contents of these cysts may present the most diverse conditions;
may be of all densities, from that of dilute serum to that of a firm jelly ;
may range between pellucidity and the thickest turbidness ; may be of
all hues of yellow, olive-green, orange, brown, pink, or nearly black.
The thick and pellucid contents of such renal cysts are enumerated as
examples of colloid matter ; so are the contents of ranulae, and of many
burssB ; but the type is the material of the so-called colloid cancer.
This, however, is beyond my present range ; and I pass by it, referring
only to the already cited works of Frerichs and Rokitansky, and to
that of Bruch,* for the best information yet supplied.
8. The last group of cysts of which I shall now speak includes such
as contain secreted fluids, like those of the glands, by the dilated ducts
or transformed elements of which they are formed. Such are the cysts
in the breast that contain milk, and probably many instances of ranula.
The origin of the former is, probably, in dilatation of lactiferous ducts;
that of the latter is uncertain. But the examples of this group, of
which I wish more particularly to speak, are the Seminal Ctsts, in-
cluding under this name those that are usually called encysted hydro-
celes, or hydroceles of the spermatic cord.f Their various forms are
fully described by Mr. Curling, J and are well illustrated by specimens
in the Museum of the College. § They are usually thin-walled spherical .
or oval cysts, imbedded in, and loosely connected with, the tissue of
the cord. They may occur singly, or in a group. Their most frequent
seat is just above the epididymis, but they maybe found in any part of
the spermatic cord. Their walls are formed of connective tissue, and
they may be lined with delicate tessellated epithelium. Their contents
are usually a colorless slightly opaline fluid, like water with which a
little milk has been mingled.
The discovery was made at the same time, and independently, by
Mr. Lloyd and Mr. Liston,|| that the fluid obtained from these cysts
* Ueber Carcinoma alveolare und den alveolftren Giewebsiypus ; in Henle and Pfenfer's
Zeitschrift, vii, 1849.
f Hydroceles of the spermatic cord are not in all cases necessarily seminal cysts. For It
sometimes happens that in infants the canalis vaginalis, although closing up at both ends,
yet does not become obliterated along its entire extent In such cases fluid may collect in
the interior of the canal, but such fluid has simply the characters of that of a common
hydrocele. In females similar collections of fluid may take place in the canal of Nuck
along the course of the round ligament. Along with these may be mentioned those Terf
rare cases in which such hydroceles of the cord, through the upper end of the canaliJ
vaginalis remaining open, communicate with the peritoneal cavity.
J Treatise on Diseases of the Testis, &c.
i Especially Nos. 2456 to 2459.
II Medico-Chirurgical Trans., vol. xxvi, pp. 216 and 368. See also, a paper by Mr.
Curling, in the Monthly Journal of Med. Science, x, p. 1023.
SEMINAL CTSTS. 371
usually contains the seminal filaments or spermatozoa. Repeated ob-
senrations have confirmed their discoYerj ; and both the existence of
these bodies, and the usual characters of the fluid, justify the speaking
of it as a diluted or imperfect seminal fluid, and, therefore, of the cysts
as ^'seminal cysts."
It was my lot, I believe, first to dissect some of these cysts ;♦ and I
found that they had no open communication or other connection with
any part of the secretory apparatus of the testicle, and that their re-
lation to the epididymis, on which they lay, was such as to forbid the
supposition of the seminal secretion being transmitted to them from the
tubes. I suggested, therefore, that these cysts were formed quite in-
dependently of the tubes ; and that, being seated near the organ that
naturally secretes the semen, they possessed a power of secreting a
similar fluid ; just as cysts beneath the hairy parts of the body may
produce hair and epidermis, and the ordinary products of the skin.
The explanation was, I believe, deemed, unsatisfactory ; but it is sup-
ported by the later investigations of other cysts, especially of those to
which I have already referred, growing in the thyroid and mammary
glands. While we find in these that perfect gland-substance may grow
from the cyst-walls, it cannot seem singular if, in a cyst lying near the
testicle or its duct, materials like the secretion of the testicle should be
formed. The growth and nutrition of gland-tissue, and the formation
of gland-secretion, are so truly parts of one process, that the proof of
the former occurring in one group of cysts removes all improbability
from the belief that the latter may occur in another group.
If, then, we may regard these seminal cysts as autogenous, and may
arrange them with those of the kidney and other glands which are de-
rived from the transformation and overgrowth of isolated nuclei or cells,
they may supply some facts of interest to the general pathology of
cysts. Especially, we may observe that in different specimens of these
"hydroceles of the cord,** or in the same at different times, the con-
tents may be either a seminal fluid or an ordinary serous fluid. In one
of the cases in which I dissected a seminal cyst, there existed, besides
that which contained seminal fluid, another larger cyst, above and
separate from the testicle and tunica vaginalis ; but this contained only
serous fluid like that of a common hydrocele. f Now this diversity is
* Medico-Chirurgical Transactions^ vol. xxvii, p. 398.
f Much has been done of late, through more careful inquiries into the structure of the
spennatic cord, to throw new light upon the mode of formation of the cysts connected with
it The obaervationB more especially of Luschka (Virchow's Archiv, p. 310, 1854), on the
itmcture and mode of formation of the cysts of Morgagni, and the discovery by Girald^s
(Gaz. des Hopitaux, Avril 17, 1858 ; Proc. Roy. Soc. Lond., May 6, 1858) of certain struc-
tures, which he has described under the name of " Corps Innomiu^,'' situated behind the
tooica vaginalis, between it and the spermatic vessels, have shown that there exist in the
cord throughout life, more or less atrophied, remains of the Wolffian body of the fcetus.
Theae ocmsist of small vesicles and convoluted tubules, which latter are short and tortuous,
and beaet with varicose dilatations. Both the hydatids of Morgagni, and the vesicles and
ccDcal tnbea of the organ of Girald^s, may undergo a dilatation into cysts. Luschka baa
872 SEMINAL CYSTS.
common among cysts. Those in the kidney may contain the materials
of urine, but they more commonly do not ; those of the lactiferous
tubes may contain either milk or some form of serous fluid ; ovarian
cysts may at one period produce hair and the other growths and secre-
tions from skin, and then, casting off these, they may produce only
serous or some other fluid.
In different cysts, this diversity of contents may sometimes depend
on difference of origin or of early construction. But when it happens
in different periods of the same cyst, it illustrates the general rule that,
in the course of time, cysts are apt to degenerate, and to produce less
and less highly organized substances or secretions. This degeneration
does not take place in any certain time ; but generally, the larger a cyst
grows, the less organized are its products; as if nearly all the forma-
tive force were expended in growth, and little remained available for
secretion. Generally, also, the longer a cyst has lived, the less orga-
nized are its products. However, both these rules are only general.
I met with a remarkable exception to them in a seminal cyst, which had
existed for seven or eight years in a man more than 70 years old. I
'withdrew from it eighteen ounces of fluid laden with seminal filaments;
and no fresh accumulation took place in the two years following the
operation. In another case, of four years' duration, Mr. Stanley re-
moved from a cyst on the right side of the scrotum 25 ounces of such
fluid, and from one on the left side 46 ounces.
I have spoken of these seminal cysts as separate from the testicle
and tunica vaginalis. Mr. Lloyd believed that, in some cases, he ob-
tained fluid containing spermatozoa from hydroceles of the tunica vagi-
nalis; and his belief was lately confirmed by the examination of a case
after death. The specimen presents the ordinary appearances of a
common hydrocele, except that the inner surface of the tunica vaginalis
is uneven, with a few small depressions or pouches from it. This hydro-
cele had been repeatedly tapped; the fluid had always the ordinary
serous appearance of that of common hydrocele ; but it always con-
tained abundant seminal filaments. Can we suppose, then, that the
tunica vaginalis has the power of secreting seminal fluid? or, were
there in this case minute secreting cysts, which, by dehiscence, dis-
charged their seminal fluid into the cavity of the tunica vaginalis, as
sometimes ovarian cysts by spontaneous openings discharge their con-
tents into one another, or into the cavity of a parent cyst ?* I am
pointed out that the former of these not unfrequenily communicate with the spermatic canaif
and contain accordingly spermatozoa. It may easily be understood, therefore, that wbeo
such an hydatid increases so as to form an encysted hydrocele, that the fluid it conttios
should have seminal filaments floating in it. But as others of these hydatids do not ooffi-
municate with the spermatic canal, they, in their cystic enlargement, will most probably
contain a fluid differing in nothing from that of a common hydrocele.
* In corroboration of the opinion expressed in the text, it may be mentioned that it is not
unusual, in examining healthy testicles, to And projecting from the sides of their bodies ioio
the cavity of the tunica vaginalis, small appendages. They are mostly situated close to the
COKPOUITD OR PKOLIFBBOUS CT8T8. 878
disposed to think this latter explanation the more probable ; but as yet
the facta are too few to justify any conclusion.
LECTURE XXIII.
COHFODND OR PROLIFEROUS CYSTS.
In the laat lecture I traced and illustrated the formation of simple
or barren cysts, — the cysts that have only liquid contents. Among
these, the instances of the highest productive power appear to be in the
cysts that secrete a seminal fluid, and those that are lined with a com-
plete secreting epithelium. In the present lecture I propose to describe
the cysts that appear to have the power of producing more highly organ-
ised, and even vascular, structures; or, as they may be generally
named, proliferona cyata.*
These inclnde such as are often called " compound cysts," or "com-
pound cystoid growths;" b\it I would avoid these terms, because they
do not suggest the difference be-
tween the cysts with endogenous Fig- *5.t
growths, and thoae that may ap-
pear equally compound, though
they are only simple cyata clus-
tered or grouped together. This
diSercDce should be clearly marked
in names, for it generally ia ao in
nature. In an ovary, for example,
such as is drawn in Fig. 45, from
a specimen in St. Bartholomew's
Huseam, it is not unfrcquent to
find many small cysts, formed,
apparently, by the coincident enlargement of separate Graafian vesi-
eleB.| These lie close and mutually compressed; and, as they all
Una or reHectitm of tbe seraua membrane. Our friend Profewoi Rollcston, of OxfoTcl, who
hu carefully examined ihem, writes ue thai he hag nacrd lubiiii seminiferi paising inu>
ibem from the bodj of tbe ienit. It is not improbable llial ibese structures may at limeB
undergD cystic dilamrioD, in which case, should dehiscence of the cysi through any cause
ocmr, seminal fluid would be discba^ed inio the shr of the tunica Taginalis.
* Drxler ibis name are here included the sero-cyslic sarcomata of Sir B. C. Brodie (Lee-
tare* oa Patbology and Surgery) ; most of ibe specimens of Cyslo-sarcoma pbyllodes and
prolifarum of Mailer (On Cancer) ; and mast of the tuberous cystic tumors of Mr. Caesar
Hawkins (Medical Gaxetle, vol. iii, p. 951}.
t Section of an ovary with many closely-placeit cysts formed by enlargement of GraaHan
I Ad obaerfalion recently made by Rokitansky (Wiener. Wochenblatt, 185S, No. l),con-
Srnii JD ■ very striking manner, tbe truth of the statement, that cystic disease of llie ovary
may r«Mill from an enlargement of the Graallan Tesicles, for he has found, in a case of in-
riirienl cyatie diiease oftba ovary, the ovule wiihiu the cyst.
874 COMPOUND OR PROLIFEROUS CYSTS.
enlarge together, and, sometimes, by the wasting of their partition walls,
come into communication, they may at length look like a single many-
chambered cyst, having its one proper wall formed by the extended
fibrous covering of the ovary. Many multilocular cysts, as they are
damed, are only groups of close-packed single cysts ; though, when ex-
amined in late periods of thrfr growth, and, especially, when one of the
group of cysts enlarges much more than the rest, it may be difficult to
distinguish them from some of the proliferous cysts.*
Of the first formation of cysts that may be proliferous I need not
speak ; for, so far as is at present known, they may be formed exactly
as the barren cysts are. A cyst may be proliferous in whichever of
the plans described in the last lecture it may have had its origin. Thus,
1. Bursse formed by expansion and rarefying of areolar spaces may be
found with organized, pendulous, or loose growths from their walls.!
2. Among the cysts formed by growth of natural cavities or obstructed
ducts, we have instances of surpassing proliferous power in the ovarian
cysts from Graafian vesicles, and of less power in some cases of dilated
lactiferous tubes and dilated veins4 And 8. Among the autogenous
cysts we find, in the breast and other glands, some of the principal ex-
amples from which the following history of proliferous cysts will be
derived.
The account given in the last lecture of the modes of origin of barren
cysts may therefore, so far as the cyst is concerned, sirffice for the
proliferous ; and I shall now need to speak of only the intracystic pro-
ductions, the differences of which may decide the grouping of the whole
division of proliferous cysts.
* This may perhaps be the bast place to speak of that form of cystic disease occurring in
the neighborhood of the ovary, which Ruysch described and figured long ago, as an hydatid
affection of the part. The cysts in these cases are characterized by their small size, com-
monly that of a pea, and rarely, if ever, exceeding an egg or an apple ; by the delicacy of
their walls; by the possession usually of a slender pedicle, and by containing a serous or
slightly gelatinous fluid. They are commonly met with in infants, and are found attached
to the under surface of the outer end of the Fallopian tube, or included between the folds of
the broad ligament. Recent careful inquiries into the structure of these parts have shown
that remains of the Wolffian body of the foetus exist after birth, and even in the adult femalei
lying near the ovary and Fallopian tube, though separable from them. To these the name
of par-ovarium, or organ of Rosenmiiller, has been given. Between the folds of the broad
ligament, and detached from the organ of RosenmQller, are a number of little ** grains," fiiA
described by Follin, which also consist of remains of the Wolffian body. The small simpte
cysts referred to in this note are caused by dilatation of the coecal tubes of Gaertner, of which
the Wolffian body is composed, and which make up the structure of the organ of Rosen-
mQller and the grains of Follin. The cysts in these cases, therefore, correspond in the
female with those already described in the spermatic cord in the male in connectk>n with
the organ of Giraldfes. See especially Verneuil in the Mem. de laSoc. de Chirurgerie, 18H
vol. iv.
f Museum Coll. Surg., 367, &c. See also, a case by Mr. Caesar Hawkins (Medical Ga*
zette, vol. xxi, p. 96 J). Perhaps, also, the case may be here referred to, in which Mr.
Hunter found loose bodies in a cavity formed round the ends of the bones in an ununited
fracture (Museum Coll. Surg., Nos. 469, 470).
^ Museum of St. Bartholomew's Hospital, Appendix 10; and see previous lecture.
COMPLEX OVABIAH CT8TB. 876
1. The firat gronp iaclades the cyste which have others growing in
or upon their wslls. Of these, two chief examples are presented, in the
complex ovarian cyete, and in the cystic disease of the chorion or " hy-
datid mole."
The principal varieties of the complex ovarian cysts have been de-
scribed to the very life by Dr. Hodgkin, to whom we are indebted for
the first knowledge of their trne pathology.* But since his minute de-
scription of them is, or should be, well known, I will more briefly say
that, according to his arrangement, we may find in these proliferous
ovarian cysts two principal or extreme forms of endogenous cysts;
namely, those that are broad-based and spheroidal, imitating more or
lesa the characters of the pa-
rent cyst, and those that are ^'S- *8.+
slender, pedunculated, clus-
tered, and thin-walled. Be-
tween these forms, indeed,
many transitional and many
mixed forms may be found ;
yet it is convenient to distin-
guish the two extremes.
A typical example of the
first is in the College Museum,!
and is sketched in Fig. 46. It
ia an Hunterian specimen ; and
the mode of preparation shows
that Mr. Hanter had clearly
apprehended the peculiarities
of its structure. It is a large
cyst, with tough, compact, and
laminated walls, polished on
both their surfaces. On its
inner surface there project,
with broad bases, many smaller cysts, of various sizes, and variously
grooped and accumulated. These nearly fill the cavity of the parent
cyst: many of them are globular; many deviate from the globular
form through mutual compression ; and within many of them are similar
but more thinly-walled cysts of a third order.
Here the endogenous cysts, projecting inwards, appear to have nearly
filled the cavity of the principal or parent cyst ; and this filling up is
complete in another specimen, in which there remains, in the middle of
the parent cyst, only a narrow space bounded by the endogenous cysts
converging in their growth from all parts of the parent walls,
e Morbid Anatomy or Serous Mem-
• Meii.-Chir. Tr«n»., iv, aSfi; and Leciur
branei, p. 221, et seq.
f Fig. 46, seclioa of b proliferous ovBriBn cyat, described
: about one-ihird or
t No. IflS.
For a topical example of the slemler, thin-walled, peduneulaled, and
clustered form of endogeneous cysts, I may adduce the Bpecimen from
the Museum of St. Bartholomew's no9pital,*whicli ia drawn in Fig. 47.
It shows part of the thick laminated wall of an ovarian cyst, the inner
surface of which is thickly
^'S- ^^t covered with crowds of pyriform
and leaf-like pellucid vesicles,
heaped together, and one above
another. This is a compara-
tively simple specimen of the
kind : in the more complex, the
endogenous cysts or vesicles are
multiplied a thousand fold, and
clustered in large lobed and
warty-looking masses that near-
ly fill the cavity of the cyst.
Specimens of this kind are
among the most valuable pos-
sessions of the Museum of Guy's
Hospital.
The College Museum fw-
nishes specimens of the forms
intermediate between these ex-
tremes,! in which the endoge-
nous cysta of the second and
third orders have walla that are
not pellucid, yet are thin and vascular, and are attached by pedicles
rather than by broad bases. Mixed forms are also found,§ in which the
parent cyst-wall bears, at one part, oval and spherical membranoiu
cysts, developed beneath its lining membrane, which they raise in low
convex projections into its cavity ; and at another part, groups of small
leaf-like, narrowly pedunculated, and pendulous cysts. Aaii, agaiD,
the same prolific power which is shown in these endogenous converging
cysts, is often, in the same specimens, shown in exogenous growths;
similar cysts, singly or in clusters, projecting from the exterior wallsof
the parent. II
But a lecture would not suffice to describe, even briefiy, the variety
of forms into which these ovarian proliferous cysts may deviate.
Whether we regard their walls, the arrangement and shape of the endo-
genous cysts, their seats and modes of origin, their various conienis,
and the yet greater difi"erence8 engendered by disease, they are so ninl-
• Series MXi, 18.
t Fig. 47, part orilie wall of a pioliretoui ovatia
j Nob. IBS a, and IBS b.
I No. SOS! in the College Museum presenla bd ii
mode* of gmwlh in ibe aame siiecimcn.
;ribpd nbove : nolural alia
CYSTIC DI8BASB OF THE CHOBIOK.
877
tiform that even imsgiDation could hardly pass the boundaries of their
dirersity. It must suffice to refer to Dr. Hodgkin's works for an
elsbontfl account of the structure and arrangement of the cysts : and
to the essajs of Dr. Tilt* for descriptions of their contents.
The foregoing account of the structure of these cyst-bearing cysts in
the oraries is derived entirely from naked-eye observations. Respect-
ing the mode of generation of the endogenous cysts, it could only be
supposed that they are derived from cell-germs developed in the parent
cyst-walls, and thence, as they grow into secondary cysts, projecting
into the parent cavity ; or, disparting the midlayers of the walls, and
Fig. 48.1
remaining quite inclos-
ed between them; or,
more rarely, growing
outwards, and project-
ing into the cavity of
the peritoneum.
Bat a more complete
Olustration of the origin
ofsuch secondary cysts,
and a good confirmation
of what I have been de-
scribing, may be drawn
from Dr. Mettenhei-
mer's investigations on
the microscopic struc-
ture of the cystic dis-
ease of the chorion. f
Some of his illustrations
are copied in Fig. 48.
The general charac-
ters of this disease, con-
stituting- the hydatid
mole, are well known.
A part, or even the
whole of the chorion is c d e
* Laneet, 1649.
t Mttliet's Archiv, 1850, H. », p. 417. His socouni, tliounh itiflcrent in inierprelalion,
ii ooniiMent, ■■ lo facts, wilh one by Gicrsennd H, Meckel, in ihe Verhandl, dor (icseiisch.
Ai GebDiUbOlfe in Beclin, ISJT. The inler|)ielstioti nilvanced by Gierae is indeed quite
oppoKd lo Mellenbeimec's view thni the cyal formaiion ia due to cntargemcm a{ the cells
or the villi, for the fotmer [PBards the cysts as ptodnceii by H simple distension of the villi,
diioagh >n accumulation of fluid in Ihe loose tissue in Iheir inlerioc. But in advancing this
interprelarioD, it appears not to have been sufficiently reconnized, that cells are found, not
ooly on tbo surlhce of the villi, but also imbedded in their substance, and that by the diiten-
non of these latter, therysl formation is produced. The opinion of Gierse has been adopted
hf Dr. Graily Hewitt, in a paper in the Tran*. OI»l. Soc., Lond., vol. i, 18.^0,
{ Fig. 48, eystic disease of the chorion, as described above : A and H, natural size; 0, D,
■, magnifled 390 lime*.
25
878 CT8TIC DISEASE OF THB CHORION.
covered with pellucid vesicles with limpid contents, borne on long,
slender, and often branching pedicles (a). The cysts are usually oval
or pyriform ; their walls are clear, or have minute opaque dots (b) ; they
may be simple, or may bear others projecting from their walls.
Dr. Mettenheimer has found that the minute dots besetting these
cysts are villous processes, exactly resembling those of the natural
chorion, and growing from the walls of the cysts, either outwardly or
into their cavities. In these villi he traced the development of cysts.
In their natural state the villi may be described as filiform or olavate
processes, often branching and bearing bud-like projections, and com-
posed pf dimly-granular substance, in which are imbedded minute nucle-
ated cells (c). In this cystic disease, vesicular bodies may be seen (as
in D and b) scattered among the cells in the villi, which bodies are dis-
tinguished from the cells by their pellucidity, their larger size, and,
when largest, by double contours; but, from the cells to these, every
gradation may be so traced as to leave scarcely a doubt that the vesicles
are derived from cells deviating from their normal characters. Thus,
in some of the cells, the contents are seen lighter and less granular;
in some they have entirely disappeared, without increase of size ; and
then, when their contents are thus become uniformly pellucid, and they
have acquired the character of vesicles, the cells appear to grow, while
their walls become stronger, and they acquire such a size that they are
recognized as very small cysts, similar, in all but their size, to those
which are visible to the naked eye.
Now, though this method of formation of cysts has been traced by
Mettenheimer only in the villi which grow on the cysts themselves, and
therefore, so to speak, only in the production of cysts of the second and
later generations, yet there can be little doubt that the first cysts in
the diseased chorion are formed in its own villi after the same manner.
For the villi which are borne on the cysts, and which to the naked eye
appear like little dots, are, in all essential characters, like those natural
to the chorion ; and the cysts of all generations are equally like. The
whole process may, therefore, be probably thus described: Certain of
the cells in the proper villi of the chorion, deviating from their cell-
form, and increasing disproportionally in size, form cysts, which remain
connected by the gradually elongated and hypertrophied tissue of the
villi. " On the outer surface of the new-formed cysts, each of which
would, as it were, repeat the chorion, and surpass its powers, a new
vegetation of villi sprouts out, of the same structure as the proper villi
of the chorion. In these begins again a similar development of cysts;
and so on ad infinitum.'' Each cyst, as it enlarges, seems to lead to
the wasting of the cells around it ; and then, moving away from the
villus in which it was formed, it draws out the base of the villus, which
strengthens itself, and forms the pedicle on which the cyst remains
suspended.
Such is the account of the minute structure and formation of the
J
PB0LIFEB0U8 CYSTS WITH VASCULAR GROWTHS. 879
cystic disease of the chorion ; and perhaps no instance could afford a
better confirmation of the production of cysts by the enormous growth
of elementary cells, or a better type of the capacity of cysts thus formed
to produce structures resembling those in the abnormities of which them-
selves originated. A similar capacity is among the characters of all
the cysts of which I shall next have to speak.
2. I pass now to the consideration of the cysts that are proliferous
with vascular growths from their internal surfaces.'*'
The first group of them may include those that bear glandular
growths — the "glandular proliferous cysts," as we may call them, be-
cause the minute structure of the substance growing into them is, in its
perfect state, exactly comparable with that of a secreting or vascular
gland.
Such cysts form part of the group to which the name of " sero-cystic
sarcoma," was given by Sir B. C. Brodie, who first clearly distinguished
them.f They are also part of those which furnished to Dr. Hodgkin
the chief ground for his well-known theory of the formation of solid
tumors — ^a theory which, in regard to at least these growths, has good
foundation.
The chief seats of the formation of glandular proliferous cysts are
the mammary and thyroid glands. Their history in the thyroid, in which
their formation scarcely passes the bounds of health, is amply illus-
trated in the often-cited works of Frerichs and Rokitansky, to which,
as well as to the essay by Mr. Simon^ on the natural structure of the
gland, I must, for brevity's sake, refer.
A series of preparations,§ such as are represented in Figs. 49, 50,
* It may be well to refer to the fact that abnormal growths upon natural free surfaces
eommonly afiect the same forms, as will be described in the fol]q,wing account of the vascu-
lar growths in cysts. The chief forms are three : namely, Ist, groups of slender, small, and
pedancnlated bodies; 2d, large round pendulous masses ; 3d, nearly level, slightly elevated
kyera, nicb as granulations. Now groups of pedunculated leaf-like processes occur on
natural free surfaces; in the growths that are so frequent in chronic rheumatic diseases of
joints, firora some of which Miiller draws his account of lipoma arboreseem; in certain
warty cancerous growths on the skin, which appear like cancerous overgrowths of the pa-
pills; and in similar growths in the larynx about the vocal cords. Of the larger, round,
pedunculated masses, growing on natural free surfaces, instances exist in the medullary can-
een of the urinary bladder, the polypi of the intestines and stomach, the pendulous out-
growths of the skin. And of the flatter, and more nearly level layers, the condylomatous
ouigrowtfat of skin, the epithelial cancers of the stomach and intestines, and the cheloid
growths, often afford examples. There is in all these resemblances a good illustration of the
tendency of the growths in cysts to imitate those on natural parts.
f The disease is admirably illustrated by the specimens in the Museum of the College,
and in those of St George's, Guy's and St. Bartholomew's Hospitals. A well-marked case
in the breast, by Busch, in Chirurgische Beobachtungen, Berlin, 1854, 8vo. p. 85, showing
much of the growth as abriormal gland-structures, and suggesting that the apparently intra-
eystic growths are projections from without. Also cases by Maur. Col lis, in Dublin Quarty.
Jour. Not. 18S0.
^ Pbiloaophical Transactions, 1844, part ii.
5 Such as those in the College Museum, Nos. 168 to 172, &c.
PROLIFEROUS MAMMARY CVSTS.
51, may clearly illustrate the corresponding prooeaa in the mammary
gland ;* but here the conditions are far more remote from the normal
typo. If we may believe that a scries of specimens may be read as the
continuous history of one case,
because they seem to present suc-
cessive phases of the same digeaae,
then, we may suppose, first the
existence of a cyat (Fig. 49), or
of a collection of cysts (Fig. 51),
in the mammary gland. Such
cysts may be formed by the dila-
tation of parts of ducts ; but much
more commonly, the cysta that
bear vascular growths are derived
through transformation and enor-
mous growth of some elementary
structure of the gland. f So far
BB I know, there is nothing pecu-
liar in the structure of the mam-
mary cysts that may be prolifer-
ous. They are usually ovoid or spherical, unless changed by mumal
compression, as in Fig. 51; they usually appear formed of thin white
fibrous tissue, with or without elastic fibres ; they have abundant blood-
vessels, and are closely adherent to the surrounding parts: their walls
are peculiarly apt in disease to become oedematous, succulent, and
almost gelatinous. They may grow to an enormous size. A specimen
is in the Museum of St. George's Hospital, in which a cyst, that woald
contain more than two pints of fluid, has some lowly lobed growths from
one portion of its inner surface ; one in the College Museum, removed
hj Mr. Listen, weighed twelve pounds ; and Dr. Warren relates a cane
in which he removed a tumor of this kind of thirteen pounds weight
The cysts may contain any of the varieties of serous or bloody Boii
clear or turhid, that I describet! in the last lecture.
Now, from some part of the inner surface of such a cyst, a vasonlu
growth may spring (Fig. 40) ; and, as this gradually increases at a »U
beyond that of the increase of the cyst, it fills more and more of iho
cavity. At length the growth wholly excludes the fluid contents of tbe
cyst, and its surfaces come in contact with the remainder of the oyst-
walls (Figs. 50, 51). The growth may now coalesce with the walls of
the cyst, and form one solid tumor, inclosed in and connected with ihen,
* All the cases recorcied have occurred in lUe femnle btpaat, Mcepi two: oocbj
Arnoii; Medicnl Oazeltc, xxii, 378 : and one by MQIler ; On Canoar, p. 180,
f Oil Ihe difference beiween llio soli.! contend of diloied 6acU, and Ibow of (h« prt* |
or Buiogenouo cysw. ace Mr, Bitkell's accoiinl in lii* Essay on the Diseases ofllie Br
I Fid!. 40. u pyji in n mammniy elanrl, lo pari of the inner nirfaoe of which «
growth is nllacheil, Below it a smbller cyst is nearly Ailed with a litnilar growth. Vo^ I
Sl Sailliolomew's : threc'lbiuths of Uie natural size.
PBOLIFHBOtJS UAHHABT CTSTS,
just as ordiDuy solid tumors are inveeted and connected with their con-
nective tisBUfl capsules.
Or growing yet further ^'K- ?*■*
and more rapidly, the
growth, hitherto intra-
cjstic, may protrude
through its cyst-walla
and the superjacent in-
teguments : protruding
through them aa a her-
nia of the brain does
through the ekull, grow-
ing exnberantly over the
adjacent skin (Fig- 51),
and, like snch a hernia,
reproduced when cut
away.
The time in which these changes may be accomplished is extremely
Tsrioua. Usually the increase of the intra-cystic growth appears to
be painless, and it may be very slow: ten years or more may pass with
little change; but the increase is generally faster, and it often ahowe
an accelerating rate; so that, late in the disease, the progress is ex-
tremely quick, even quicker than
that of most cancerous growths.
The characters of the intra-
cystic mammary growths are
various, not only according to
onr observationa of them at dif
ferent periods of their existence,
but, apparently, even from their
very origin. In looking through
a large series of them while they
are still in early periods of their
development, we may reduce
them to these chief forms ; name-
ly, low, broad-baaed, convex lay
ers, like coarse granulations,
spheroidal, lobed, and nodulated
maaaes, cauliflower-like, attached
by narrower bases (Fig. 49),
maasea or clusters of peduncu-
lated leaf-like processes, slender.
< Fig. so, a cjt\ in the mai
cf pedoDODlmled processea. i
f Fig. SI, colleeiionof cysr
mamiiutr; gtand: dcachbed oi
Fig. 51t.
iniarjr gland filleil wllh H vasriitat growth bearing cluslcri
us. Coll. Surg. Nalural size.
filled with glanilulBr giowihs in and prolruJing rrom tha
(he next page. Hair the natural size.
882 PB0LIFBR0U8 MAMMARY 0TST8.
single, or varionslj branched, and interlaced in all possible forms
(Fig. 50) ; masses of firmer and much paler substance, appearing as if
formed of close-packed lobes, or fimbriated processes, or involuted layers
(Fig. 51).
In apparent structure, also, the varieties of these growths are scarcely
less numerous. Some of them are opaque, yellow, and soft, yet elastic,
and rather tough, so as to be separable in laminae like a fibrine clot;
others are more vascular, succulent, and spongy, like granulations;
others are like layers and masses, or heaped up layers, of gelatine, not
firmer than size, or even like vitreous humor, yielding a tenacious syno-
via-like fluid : others are firm, compact, nearly pure white, imitating
the mammary gland, but not succulent.
To these varieties of appearance we might add yet more, due either to
diverse shades of yellow, pink, gray, or purple ; or to the various clus-
tering and incomplete fulness of the cysts ; or to the increasing firm-
ness of the growths, and their fusion with the cell-walls; or to the
development of new barren or proliferous cysts in the solid growths
that now fill the cysts of a former generation ; or to various changes of
decay or disease ensuing in either the cyst-walls or their contents.
It would be too tedious to describe all these varieties, especially while
we do not yet know whether, or in what degree, these forms are related
to one another, or to any one typical condition of the intra-cystic
growths.
Respecting their minute structure, we have good guidance in the
probability, which will be supported in the twenty-eighth lecture, that
the proper mammary glandular tumors — the chronic mammary tumors
of Sir A. Cooper — have their origin in intra-cystic growths, transformed
into solid tumors in the manner just described. The mammary glan-
dular tumors are composed of minute structures closely imitating those
of the gland itself. They present microscopic lobes, and fine tubules,
lined or filled with nuclei and nucleated cells, like those of secreting
organs ; these, inclosed within pellucid membrane, form a pseudo-glan-
dular substance, such as, we might suppose, needs only a main duct to
enable it to discharge the office of a mammary gland. In the like
manner and degree, in some specimens in which the cysts and their
contained growths are still easily separable, we can discern in the
growths a likeness to the mammary gland itself in their minute struc-
ture.
These facts have been observed especially by Mr. Birkett,* and were
very well marked in a case which I was able to examine, and of which
Fig. 51 represents a section. It was a very large protruding tumor of
^the breast, removed by Mr. Lawrence from a lady 55 years old. It
had been observed for thirty years, remaining like a small knot for
* Especially in bis Essay on Diseases of the Breast, and in the Guy^s Hospital Repoftii
1855.
I
i
PBOLIFEROUS MAMMARY CTSTS. 888
twenty-six years, and then slowly increasing, till, at the end of five
years, a red fungous mass protruded from the breast, bled freely some-
times, and discharged profusely. This, too, increased quickly, and was
painful. The whole breast was removed, and the patient recovered.
The tumor (Fig. 51) measured nearly seven inches by five. The part
which did not protrude beyond the level of the skin was imbedded in
the substance of the gland. It consisted of numerous lobes of various
sizes and shapes, and variously divided into smaller lobes ; all being
evidently formed of distinct cysts closely packed and compressed toge-
ther. Most of these cysts were filled with intra-cystic growths ; yet
in many of them it was easy to pass a probe between their walls and
the surfaces of their contained growths, which were fixed to only one
part of the cyst-walls. In the protruding part, of which the overhang-
ing outer border is shown in the sketch (Fig. 51), the same general plan
of structure could be discerned, but less distinctly.
Among the solid growths that filled the cysts, some showed clavate,
close-packed lobes ; some were nearly simple ; nearly all were pale,
white, grayish or yellowish, and smooth and shining ; a few were spotted
with yellow, from degeneration of their tissue. Repeated examinations
showed that all these consisted essentially of a tissue imitating that of
a gland, and such as will be described in the twenty-eighth lecture.
The edges and surfaces of the examined portions were minutely lobed
or acinous, like terminations of gland-tubes. These were inclosed by
well-defined, pellucid membrane : and their cavities were full of nuclei
and nucleated cells, like mammary gland-cells, with some granular
matter. Except in that these acini led to no distinct ducts, but seemed
confusedly heaped together, the imitation of gland-structure was com-
plete.
Now, the glandular nature of these growths in the best-marked cases
of proliferous mammary cysts, and the probably constant relation of the
mammary glandular tumors to them, as well as the analogy of the intra-
eystic thyroid growths, may seem to make it probable that, in alt cases,
the growths within the mammary cysts are of essentially the same glan-
dular nature, and that their various appearances are due to their being
in rudimental, or degenerate, or diseased states. But we cannot be
sure of this. In three cases, in which I have minutely examined soft
intra-cystic growths, I could not recognize a glandular structure. In
all, I found a basis-substance, which was pellucid, soft, and in one case
diffluent ; it had little or no appearance of fibrous structure, and no dis-
tinct fibres, but, rather, presented the uniformity as well as the consis-
tence of soft gelatine. In it, as in a blastema, were imbedded nuclei
and cells, which chiefly presented the forms of developing connective
tissue, like those in granulations, or of inflammatory lymph : or their
forms might be explained, I think, by the disorderly conditions of their
production and development. Nearly similar, and equally indecisive
884 VARIOUS PROLIFEROUS CYSTS,
results appear from an accurate observation of such a growth by Dr.
Mettenheimer,* and from two cases related by Bruch-f
Perhaps we may conclude that, in these specimens, the intra-cystic
growths were in a rudimental, or in a morbid state ; that the general
destiny of such growths is towards a glandular structure, but in these
and the like instances they fell short of it, or swerved from the right
course. But I w'ould rather not form any conclusion at present. These
are just the cases of which, as yet, the interpretation is scarcely possi-
ble, while we are ignorant of the changes that may ensue during de-
velopment, degeneration, and disease.
I have said that the mammary and thyroid glands might be regarded
as the elected seats for cysts having glandular growths ; but they are
sometimes met with in other parts, as in the prostate, and, I believe,
also in the lip. In the Museum at St. George's Hospital is a tumor
removed from a man's upper lip, in which it had been growing, without
pain, for 8J years. One-half of it is a cyst that was filled with a thin
flaky fluid, and was thought to be a dilated labial gland-duct ; the other
half is a solid tumor, just like a glandular tumor of the lip which I shall
describe in a future lecture. I have lately seen another case with
nearly the same characters : and the combination of a barren cyst with
a proliferous one, which they seem to illustrate, is not rare in the mam-
mary gland. In the same Museum is a cyst, with a broad vascular
growth, like granulations, from its walls, which was taken from a girl's
labium by Mr. Cutler. It has a small external opening, suggesting
that it may have had its origin in a cystic mucous or sebaceous gland.J
In the College Museum, No. 167, is a thick-walled cyst, from the cheek
of an old woman, which contains two large, lobed, and pedunculated
masses, so like some of those found in the mammary cysts that we can
hardly doubt their glandular nature.
All these specimens, however, need more minute examination; at
present they only make it probable that any cyst originating in or near
a secreting gland may be the parent, or the habitation, of an endog
nous glandular growth.
To this account of glanduliferous cysts it must be added, that thek
characters may be closely imitated by cysts formed in parts altogeth
unconnected with secreting glands. It is not, indeed, probable th^t
the contained growths in such cysts are glandular; yet they present
characters like the softer growths that are found in the mammary cysts*
* Mullers Archiv, 1850, p. 207.
t Die Diagnose der bosartigen GeschwGlste, pp. 185, 191.
X See also an account of a specimen in the same Museum, by Mr. Hawkins: Medical Ga-
zette, xxi, p. 951 ; and Proc. of Pathol. Soc. ii, p. 310. I suppose there is some relation
between these and the subcutaneous warts and condylomata described by Hauck and
Kramer ; but I have not seen what they refer to. (See Simon : Hautkninkheiten, p. 2*2.).)
VARIOUS PROLIFEROUS CYSTS. 885
I found one of these proliferous cysts beneath the gracilis and ad-
ductor longus muscles of a woman twenty-five years old. It was a
large spheroidal mass, which felt as if held down tightly on the front
of the pelvis, and had pushed the femoral vessels a little outwards. It
lay too deep to form a clear diagnosis of its nature ; it was assigned to
no distinct cause ; it had been noticed for only seven months, but when
first seen was " as large as a tea-cup." I removed it without much
difficulty ; for it was not closely adherent to the parts, except to a small
portion of the front of the pubes, where it rested on the adductor bre-
vis. The patient has since remained well for more than three years.
The tumor was spheroidal, about four inches in diameter, and con-
sisted chiefly of cysts, from two of which six or eight ounces of turbid
serous fluid escaped when they were cut across. One of these cysts was
thickly lined with pale, brownish, fibrinous substance, like that which
one finds in old hsematoceles ; and this appeared as fibrine on minute
examination. Another was nearly filled with a ruddy mass, in most
parts soft and succulent, like blood-stained gelatine. Much of this
mass was also like fibrine-clot, with abundant corpuscles ; but the
layers of it next the cyst-walls were firmer than the central parts, ai\d
contained all the forms that one finds in common granulations develop-
mg into connective tissue. The microscopic likeness to granulations
was, in these parts, exact. The rest of the tumor, including some large
portions between the cysts, consisted of connective tissue more or less
perfectly developed.*
A similar tumor was removed by Mr. Lawrence from the exactly cor-
responding part of a woman 50 years old, in whom it had grown slowly,
and without pain, for nine or ten years. It gave the sensation of a
firm fatty tumor, as large as an egg, but when removed was found to
be a bilocular cyst. Each cavity contained, together with serous fluid,
a soft, reddish, gelatinous-looking mass, like a polypus in one, and solid
and folded in the other. The cyst-walls were tough, pure white, formed
of connective tissue, and polished on their inner surface. The in-
tra-cystic growths consisted of a structureless or dimly granular or
fibrillating blastema, with abundant oily molecules, granule-cells, and
corpuscles, like nuclei, imbedded in it.
And to these two instances, since the disease seems very rare, I may
add a third. A girl twenty-three years old, under the care of Mr.
liawrence, had a pyriform pendulous tumor in her neck, about 2 J inches
long. Its surface was ulcerated, livid, and painful, and bled occasion-
ally. Its history was doubtful ; but it had existed for at least a year.
On removal, it appeared to have grown in the subcutaneous tissue, and
to be composed of a collection of cysts, closely and irregularly packed,
and, for the most part, filled with lobed, soft, cauliflower-like growths
from parts of their walls. It closely resembled, in its general aspect,
* The tumor is in the Museum of St. Bartholomew's Hospital.
886 VARIOUS PROLIFEROUS CYSTS.
the collections of proliferous cysts, with soft intra-cystic growths, in the
mammary gland. In microscopic structure the intra-cystic growths ap-
peared composed entirely of corpuscles, like those of lymph or granu-
lations : but my record of the examination, made several years ago, is
too incomplete for a clear account of them.
I believe that all the cysts that I spoke of, before these that contain
vascular growths, may be regarded as completely void of the characters
of malignant disease ; at least, I have met with no evidence contrary to
this statement, except in certain cases of proliferous ovarian cysts, to
which I shall presently refer. And, in general, the reputation of in-
nocency is deserved by the glanduliferous cysts also. Yet there are
cases which show that such tumors may have an exceeding tendency to
recur after removal.
A healthy robust woman, 87 years old, was under Mr. Lawrence's
care with a very large protruding tumor in her right breast. This had
been slowly increasing for ten years, but, till lately, had given little
uneasiness, except by its bulk, and had not hindered her nursing. Mr.
Lawrence removed the greater part of the breast and the tumor in 1844.
It weighed 7} pounds, and was a well-marked example of that form of
" sero-cystic sarcoma," in which the cyst- walls, as if altered by inflam-
mation, or imperfectly formed, are soft, succulent, and glistening, with
solid growths of similar substance, lobed and fissured. Many cysts in
it still contained serous fluid. Its appearance when recent, and even
now as preserved,* leaves no room for doubt as to its nature.
The patient remained well for fifteen months ; then a tumor began
to grow under the scar, and quickly increased. After nine months*
growth Mr. Lawrence removed this also, with all the surrounding tis-
sues. It was a pale, pinkish, and yellowish mass, like soft size or jelly.
It was lobed and folded, and included some irregular spaces, containing
a fluid like mucus or half melted jelly. It was like the solid parts of the
tumor last removed, and consisted of a pellucid dimly fibrillated blas-
tema or basis-substance, in which were imbedded nuclei and abundant;,
granule-cells, of various forms. The sketches and account of these.^.
which I drew at the time, make me still sure that they had none of th^
characters of cancer-cells, but were like nuclei of ordinary form, (vx:
elongated, many of which were changed by fatty or granular degenerak-
tion.
After this second operation, the patient remained well for seveB
months, and fully regained her stout robust appearance. But now a
third tumor appeared ; a fourth soon after ; and both grew rapidly, tii/,
after two months, Mr. Lawrence removed them, and all the parts bound-
ing them. They were, in every respect, exactly like those removed ifl
the last operation, and near them lay another not discerned before the
removal. Erysipelas following this operation proved fatal, and no post-
mortem examination could be obtained.
* In the Museum of St. Bartholomew's, Ser. xxxiv, Nos. 19 and 20.
BECURRING PROLIFEROUS OTSTS. 887
Now in the first of these operatioos some portion of the mammary gland
was left. It is possible that some cysts already existed in this portion,
and were subsequently developed into the second tumor, which, there-
fore, might not deserve to be called a recurring tumor, although, indeed,
it appeared under the scar of the former operation, and not in the
place where gland- substance was left. But, after the second operation,
there is little probability that any gland remained ; and we may, with
as little doubt, regard the third tumor as an instance of recurrence
or repetition ; t. e. of reappearance of the disease in an entirely new
growth.
Sir B. C. Brodie* has related two cases of single recurrence of tumors
very closely resembling that just now described; and the liability to
recurrence which Mr. Lawrence's case presented is surpassed by one
recorded by M. Lesauvages,t whose description of the tumors he re-
moved accords so closely with what was observed in the foregoing case,
that I can have very little doubt they were of the same nature. The
patient was 63 years old. The first tumor of the breast, which was of
great size, was removed in February, 1832 ; a second appeared, and
was removed before the healing of the first wound ; a third in May ; a
fourth in September of the same year ; a fifth sprang up, and was re-
moved in February, 1833 ; a sixth in May ; in a seventh operation,
in June of the same year, three tumors were removed ; but from the
same spot two more arose, and these grew rapidly, and the patient
died.
Now if, as I believe, all these cases and others that I have seen,
were examples of the proliferous cystic disease of the breast, they prove
such an inveterate tendency to recurrence in this disease, as is scarcely
surpassed by any even of the well-marked malignant tumors. Unfortu-
nately, no examination of any of the cases was made after death ; so
that it is not possible to say whether the more characteristic features of
malignant disease existed, such as the concurrence of similar disease in
internal organs. The same defect does not exist in a most remarkable
case related by Dr. Cooke.J The patient was about 40 years old when,
in April, 1847, six ounces of a glairy brown fluid were drawn from a
cyst in her breast, which formed part of a large tumor that had been
Rowing for seven months, and felt in some parts firm, in others soft
and fluctuating. Occasional tappings were subsequently employed;
but after five or six weeks the integuments inflamed and sloughed over
the cyst, and a profuse discharge of similar glairy fluid ensued. " Fun-
goid masses" soon protruded, and in July, 1847, Dr. Cooke removed the
whole disease. It weighed 3^ pounds, and consisted of fungoid masses
of various degrees of firmness, with a central cavity lined by a vascular
membrane. In December of the same year, a small enlargement on the
* Lectures on Pathology and Surgery, p. 145.
t Archives G^n. de M^decine, F^yrier, 1844, p. 186.
^ Medical Times and Gazene, August 7, 1852.
388 CANCEROUS PROLIFEROUS CYSTS.
scar was removed. In March and in October of the next year (1848),
renewed growths were again removed. In 1849 the disease again re-
turned, and was extirpated in June, 1850. This was "a miniature
representation of the tumor removed at first;*' and it was examined by
Mr. Birkett, who reported of it, that, '* in a stroma of fibrous tissue
cysts appeared, containing a yellow tenacious fluid. The follicular
terminations of ducts of glands were very distinctly seen in the fibrous
tissue, and nucleated corpuscles : within these follicles were clearly seen
the elements of the epithelium of glands." The patient recovered rapidly
from this last operation, and no recurrence of the disease in the breast
again ensued ; but in June, 1851, she began to suffer with what proved
to be cancer of the peritoneum, liver, pleura, pelvic organs, and lumbar
and thoracic lymphatic glands. When she died, in November, 1851,
abundant cancerous disease was found in all these parts : but the seat
of former disease in the breast was healthy, and, as Mr. Birkett es-
pecially remarks, all the lymphatic glands connected with the breast
were, as they always had been, unaffected, while all those connected
with the cancerous parts in the pelvis and elsewhere were the seats of
cancer.
The fact last mentioned makes it improbable that the cancerous dis-
ease with which this patient died was continuous with, or a part of, the
disease which had been manifested in the breast. Rather, we may
believe that the two affections were essentially distinct, and that the
first was, like the others I have related, an example of recurring
proliferous cystic disease. But further inquiries are necessary to eluci-
date these cases ; at present, they are obscure in all but their practical
import, and in their proof that the cystic disease of the breast, though
generally a completely innocent disease, is, in certain cases, pecu-
liarly prone to recur after removal. In this view they will again be
referred to, in the lecture on recurrent tumors, and in the lectures on
the general pathology of cancers.
3. It may be inserted here, that the mode of growth observed in the
glandular proliferous cysts may be imitated by genuine cancerous
diseases.
Cancerous growths may be found in cysts under at least two condi-
tions ; namely, in cysts that of themselves appear innocent, and in
cysts produced within cancers.
Of the former mode of growth we have the examples in ovarian
cysts, to which I just referred ; and herein are, perhaps, the only un-
exceptionable instances of the transformation of an innocent into »
malignant tumor.
The second mode of production of intra-cystic cancers is best shown
in some examples of medullary tumors of the testicle. In these* we
* As in Mu8. Coll. Surg., No. 2396.
CUTANEOUS PROLIFSROUS CYSTS. 889
may see a repetition, so far as the plan is concerned, of the intra-cystic
production of thyroid gland. The great mass of the medullary disease
includes smaller masses, incapsuled with connective tissue, and com-
monly presenting a lobed and laminated form, at once reminding us
of the intra-cystic glandular growths, and justifying the application
to them of the principles of Dr. Hodgkin's theory of the growth of
cancers.
In these medullary testicles the intra-cystic medullary growths have
usually filled the cysts and coalesced with their walls. In rare cases
one can discern how the growths spring up as spheroidal, or as peduncu-
lated, branching, and grouped processes from the interior of the cysts.
This condition was peculiarly well shown in a case of ^cancer of the
clitoris, in which the whole of that organ was occupied or concealed by
a cancerous mass inclosing, several distinctly walled cysts, which were
half-filled with small, soft, and lobed cancerous intra-cystic growths.*
4. I proceed to the consideration of the cutaneous 'proliferous cysts ;
t. e, of cysts within which, in the typical examples, a tissue grows,
having more or less the structure and the productive properties of the
skin.
Instances of these in a perfect or typical state are rare. In the
large majority of cases the cutaneous structure, if it were ever present,
has degenerated or disappeared ; and we recognize the relations and
import of the cysts only through their containing epidermal and sebace-
ous materials, of which the natural production is a peculiar attribute of
the tissues of the skin.
Among the parts in which these skin-bearing cysts may be found are
some that have no natural connection with the skin.
1. They are frequent in the ovaries ; one or more Graafian vesicles
enlarge and grow, and then, apparently, produce on their inner surface
a growth of skin, with its layer of cutis, subcutaneous fat, epidermis,
* Museum of St. Bartholomew's, Ser. xxxii, 39. Rokitansky gives to cases of this kind
the name of cystOK^arcinoma, and draws a just parallel between them and the instances of
cysto-sarcoma. (Pathol. Anat. i, p. 390.) Cysto-sarcoma he regards, nearly following MQller
herein, as a combination of sarcoma with cyst- formation. The cases included by him and
M&ller (On Cancer, p. 170) under the name, cannot be nil inclosed in the groups which 1
bare brought near together. (1.) Some are cases in which simple cysts are found within
lolid tumors: these are named cysto-sarcoma simplex, and such as these will be mentioned
or referred to as varieties of fatty, fibrouii, fibro-plastic, and cartilaginous tumors, in all of
which the formation of cysts may ensue. (2.) The cysto-snrcoma proliferum. if it be cor.
rectly deacribed as constructed of cysts contained in a solid tumor, and containing younger
CjftU in their interior, I have never seen. The case to which MUller refers as exemplifying
it, and which is figured by Sir A. Cooper (Illustrations, p. 11, pi. iii), was, I believe, an in-
stance of proliferous glandular cyst in the manmmry gland. (3.) The cy.sto-sarcoma phyl-
lodes it a proliferous glandular cyst of the breast, and is especially exemplified by the cases
in which the intra-cystic growths are firm, lobed, pedunculated, and clustered, and in
which many cysts are close-set in the breast. But in this disease there is, I think, no solid
tmrnor in which the cysts are set: they appear to be themselves the primary disease, the
solid growths within them being secondary formations; and if this be true, they cannot
properly be grouped with the examples of MQller*s cysto-sarcoma simplex.
890 CUTANEOUS CYSTS.
and all the minute appended organs of the proper hairy integomentB of
the body. The general likeness of the interior of these cysts to
ordinary skin had been often noticed ; but the first minute demonstrar
tion of it was by Kohlrausch,* whose observations have been fully con-
firmed by others as well as by myself. Among the specimens in the
College Museum, one (No. 164 a) presents all the textures of a hairy
piece of skin growing on the interior of one of the cavities of a large
multilocular ovarian cyst. Of the other divisions of the same cyst,
some contained fatty matter and loose hair; others, various fluids;
others, secondary and tertiary cysts : and this is commonly the case.
Another specimen in the College Museum (No. 2624) shows very well
the origin of these skin-bearing cysts. It is an ovary, with a cyst, the
small size of which, as well as the structure of its walls, and the mode
in which they are connected with the surrounding substance of the
ovary, leaves no doubt that it is a simply enlarged Graafian vesicle.
Yet it contains some hairs, and a small mass of fat, resembling the
subcutaneous fat, with its tough connective-tissue partitions.
2. Cutaneous proliferous cysts may form in the subcutaneous tissue.
They are, indeed, rare in this tissue in man, except in cases of con-
genital growths. In the little cysts about the brow, or in or near the
orbit, the inner surface is often perfectly cutaneous ; and Lebertf has
detected in such cysts all the minute structures and organs of the 8kin.|
Most of these cysts are first observed at or soon after birth. Some
similar specimens of cysts lined with skin are in the Museum of the
College. § These were taken from the subcutaneous tissue of a cow
and of an ox ; and, in some of them, the inner surface of the cyst
could hardly be distinguished from the outer hairy integument of the
animal. II
3. Besides these, the common seats of cutaneous cysts, perhaps any
part or organ may in rare instances present them ; for the records of
surgery and pathology would furnish abundant instances of aberrant cysts
containing hair and fatty matter, such as we must class with these in
which the cutaneous structure and products are more perfect. The most
singular and frequent of these rarer examples are in the testicle,^^ the
* Miiller's Archiv, 1843, p. 365. A careful description of the structure of these skin*
bearing cysts in the ovary, by Dr. Steinlein, may be found in the Zeitsch. f. Rat, Med^ voL
ix, p. 146.
f Abhandlungen, p. 99, e. s. The structure is well shown in No. 158 in the Collegs
Museum.
J Mr. H. Walton, in his " Remarks on Tarsal Tumors" (Med. Chir. Trans., xxxvii, p. ^i
1854), suggests that the name of Meibomian cysts should be given to the so-called tarsal
tumors. He considers them to be dilated and grown Meibomian glands, with cuticular, or
sebaceous, or degenerate, or puriform contents, and sometimes with vascularized and pe^
haps glandular intra-cystic growths.
§ Nos. 161, 163, &c.
0 In Mus. St. Bar. is a specimen of a cutaneous cyst, containing hair, obtained from thfl
scalp. See Med. Times and Gaz., Dec. 16, 1853.
IF See Goodsir, in Edinb. Monthly Journal, June, 1845.
8BBA0E0U8 AND EPIDERMAL CYSTS. 391
lung,* the kidnejyt ^^^ bladder ;% and under the tongaey§ and within
the skull or brain. Those in the brain are of chief interest. I found
one|| many years ago in an elderly man. While he was in St. Bar-
tholomew's Hospital with an ulcerated leg, he suddenly died ; and the
only probable cause of death appeared to be a mass of granular fatty
matter mixed with short stiff hairs, which lay in the tissue of the pia
mater under the cerebellum.
A yet more remarkable case is in the Museum of St. George's Hos-
pital, in Mr. Csesar Hawkins's collection. It exhibits a mass of fatty
matter, and a lock of dark hair 1^ or 2 inches long, attached to the
inner surface of the dura mater at the torcular Herophili. This was
found in a child two and a half years old, in whom it appeared to have
been congenital.^
It is perhaps only during the vigor of the formative forces in the
foetal or earliest extra-uterine periods of life, that cysts thus highly or-
ganized and productive are ever formed. The aebaceouSj epidermal^ or
eutieular cysts that grow in later life are imperfect, impotent imitations
of these ; yet clearly are the same disease, and are, therefore, most
naturally classed with the proliferous cysts, needing only to be named
according to their contents. We cannot tell, in any advanced case of
such a cyst, whether the more complicate structures of the skin ever
existed ; if they did, they have degenerated before the cyst became of
distinct size ; yet the retained likeness is sometimes shown in the fact
that, when such cysts are laid open to the air, they do not granulate,
but assimie for their internal 3urfaces the characters of the adjacent
and now continuous skin.**
Of these sebaceous or epidermal cysts, it is interesting to notice the
frequent hereditary origin. Perhaps, in the majority of cases, the
bearers of these have known one or more members of their family simi-
larly endowed. They are certainly more commonly hereditary than
are any forms of cancer.
I have already referred to the double mode of origin of the epidermal
* KdlUker, in the Zeitochrifl itlr wissensch. Zoologie, B. ii, p. 281. Cioetta in Virchow's
ArcbiT, vol. zx, p. 42, 1860.
t Mus. Coll. Surg. 1904. % ^"s. Coll. Surg. 2626.
{ Scbub, Pseadoplasmenf p. 154; and Mus. St Bartholomew's, Ser. xxxv. No. 25. Hut*
ebinson, Med. Times aud Gaz., Dec. 31, 1853.
II Mas. St. Bartbolomew's, Ser. vi, 56.
f Dr. J. Ogle has carefully described this specimen in the Trans. Path. Soc., vol. vi, p.
12. He is of opinion .that the cyst was originally of extra-cranial formation, but that at
an early period of festal life, before ossification of the occipital bone had taken place, the
Cerebral membranes and scalp had become adherent, and that as the development of the
boDe went on, the outer integument was drawn in by retirement of the cerebral mem-
branes. In this way some of the cutaneous structures would become included within the
cmoiuDi. He considers that the cyst possesses characters which warrant the above sup-
position. In a similar manner, perhaps, cysts within the orbit may extend into the cranial
cftTity.
** See Home, Hunter's Works, vol. iii, p. 635 ; and a remarkable case by Mr. Green, in
fhe Medial Gazette, vol. ii, p. 346.
892 SEBACEOUS AND EPIDERMAL CT8TS.
cysts. Sir Astley Cooper first observed that some among them could
be emptied, by pressing their contents through a small aperture in the
cutis over them, and hence concluded that they are all examples of
hair-follicles distended with their secretions, and overgrown : but pro-
bably this conclusion is true for only a minority of these cysts. They
are, I think, comparatively few, in which an aperture can be found ;*
the greater part are closed on all sides alike, and must be regarded as
cysts new-formed. I suspect that those cases are equally, or more rare,
of which Lebert and Bruns have described instances,t characterized
by the existence of a slender cord, traceable from the cyst to the skin,
and formed of the obliterated duct of the enlarged and obstructed air-
follicles.
The characters of these epidermal cysts may be extremely various,
in regard not only to their walls, but to their contents. Their walls
may be thin, delicate, and pliant ; or laminated, thick, and hard, with
tough fibrous tissue ; or they may be calcified ; and I believe a general
rule may be connected with the differences in these, as in other cysts,
namely, that the thin-walled are the most productive, grow most rapidly,
and are the, seats of the most active change. J
* Mr. South especially notices this in his edition of Chelius's Surgery, toI. ii, p. 698. See
also Walther, in Vogel's Pathol. Anat. p. 224. Professor Porta, in an essay devoted to the
consideration of follicular sebaceous tumors (Dei Tnmori Folliculari Sebacei, Milano, 1856),
agrees with this statement. He supplies some statistical information respecting the fre*
quency of occurrence of the different kinds of cysts. He has met with 384 specimens; 23
patients, having from 2 to 20 cysts each, supplied 72 of the specimens. Of the 384 cytts,
270 were on the head and face, 1 14 on other parts of the body, 257 were subcutaneous; 127
(including IH encysted hydroceles) were deep sealed, 41 were congenital, the others originated
at various limes of life, and had various progress. Of the 384 cases, 238 were examples of
cutaneous cysts of new formation, 78 (including those of encysted hydroceles) were cases
of hygroma, 15 were hcrmatoid or sanguine(»us cysts, 9 calcareous cysts, 4 echinococcui
cysts, 14 suppurated cysts, and 26 were such sebaceous follicular cysts as he has made the
chief subject of his essay. Of these last-named he describes cases of a kind of cutaneous
tumor of the face, composed chiefly of numerous hair-follicles, or sebaceous glands, arranged
in groups and all moderately enlarged (see hisPl.iii).
t Virchows Archiv, viii, H. ii, p. 222.
X Wernher, in Virchows Archiv, viii, p. 221, has described the walls of the epidermal
cysts as possessing a more complicated structure than has been hitherto recognized. Ex-
cluding those formed of dilated hair-follicles, which are very few, he states that the cysts
have two layers in their walls: an external formed of connective tissue, and an internal, in
places thin and membranous, but in others much thicker, irregular, or like cartilage. Im*
bedde<l in die substance of the internal cyst-wall, especially in its thick nodular parts, are
collections of laminated epidermal capsules, and in some instances all the other usual con-
tents of epidermal cysts. In the later stages of the growth the stniclures imbedded in the
cyst-walls may become inclosed in thin cysts, which may afterwards split and gradually
discharge their contents into the main cyst cavity, in which case they are found as heaps of
epidermal structures, set on the surface of the outermost layer of the epidermal contents of
the main cyst. Whenihus emptied, the inner surface of the inner layer of the cyst- wall has
cavities, or reticulated <lepressions, corresponding to the emptied-out collections of epitle^
mal structures. It may be, however, a question whether the interpretation put by Wern-
her on these collections of epidermal structures within the innermost layer of the cyst-wall,
viz., that they are first formed, and subsequently encysted, is the correct one. It is more
probable that they are abortive or imperfect follicular structures, representing the completely
formed follicles, glands, &c., of the best and most perfect cutaneous cysts.
8BBA0B0US AND EPIDERMAL CYSTS. 893
Among the contents of these cysts we may observe extreme varie-
ties. The chief alone need be referred to. And 1st, we find successive
productions of epidermis, formed in layers on the inner wall of the cyst,
and thence successively shed, and pushed inwards towards its centre.
A section of such cysts (which were particularly described by Sir Eve-
rard Home from the Hunterian specimens) presents layers of white soft
epidermis, like macerated epidermis of the heel or palm. The external
layers are commonly quite regular, white, and flaky ; but the internal
are more disorderly, as if degenerate, broken up, or liquefied, and min-
gled with less organized productions.
2dly. A peculiar appearance is given to contents like these, where,
among the layers of epidermal scales, abundant crystals of cholesterine
are mingled. They hence derive an appearance like that of the masses
to which Muller* has given the name of cholesteatoma, or laminated
fatty tumor ; and, indeed, the few well-marked examples of this disease
which I have been able to examine, as well as Muller's own account,
make me think that what he named cholesteatoma is only a combina-
tion of layers of epidermal scales with crystals of cholesterine.f
The appearance produced by such a combination is quite peculiar.
It forms nodular masses of soft and brittle substance, like wax or sper-
maceti, the surfaces of which present a bright glistening, like that of
mother-of-pearl, while their sections are finely laminated. It is a rare
disease ; the most frequent seats of well-marked specimens appearing
to be in ovarian cysts, and in connection with the membranes of the
brain. The characters are well shown in the contents of a small ova-
rian cyst in St. Bartholomew's Hospital ; and in the tumor within the
occipital part of the cranium, in Mr. Hawkins's collection, to which I
have already referred. Striking examples are figured by Cruveilhier ; J
but the want of microscopic examination leaves their constitution un-
certain.
3dly. In the opposite extreme to these cysts, in which the cuticular
product is most perfect, we find an innumerable variety of contents, of
* On Cancer, p. 155.
f S<»e, also, an account of siuch a case by Mr. W. Adams, in Proc. of Pathol. Soc., 1850-1.
Other writers since Miiller have applied the name of cholesteatoma more vaguely. Vir-
chow, in an essay in his Archiv, B. viii, p. 371, 1855, shows theneedof distinguishing, more
than is commonly done, the true cholesteatoma of Miiller from mere collections of chole-
tterine crystals in cysts, dried-up abscesses, surfaces of ulcers, &c. He terms the true chole-
tteatoma Perl-geschwulst, ^ pearly tumor," and points out that its essential characters are con-
centricaliy laminated, flat epidermoid cells, with interspersed cholesterine crystals. He
admits the similarity between some cases of cholesteatoma and the cutaneous proliferous
eytts, but is of opinion that there are others, and he cites two which grew in the pia mater
which came under his own observation, to which no such cutaneous origin could be as-
cribed. He gives also cases of cystic tumors in the testicle in which cholesterine pearls
were Iband. He thinks that in such cases they may Be formed from the epithelial struc-
tures of the seminal tubes. An illustrative case in the scalp is recorded by Volkmann in
Vifcbow*fl Arohiv, vol. xiii, p. 46, 1858.
X ADatomie Pathol., liv. ii, p. 6.
26
394 SEBACEOUS AND EPIDERMAL OTSTS.
buff- and ochre-yellow, and brownish materials, that seem to consist
mainly of degenerate cuticle mingled with sebaceous secretions. The
microscope finds in them a confused mass of withered scales, of granular
fatty matter, clustered and floating free, of cholesterine crystals, and
of earthy matter in free molecules, or inclosed within the cells or scales.
And all these may be floating in a turbid liquid, or retained in some
soft tenacious mass, or clustered in hard nodular and pointed masses,
projecting like stalactites from the old cyst-walls.*
One more phase of this disease deserves especial notice, — that in which
the cyst ulcerates, and its contents protrude. An inflammation in or
about the sac often appears the inducement to this change ; and some-
times the inflammation itself can be traced to nothing but disturbance
of the general health. The probability that it may thus arise makes
the caution very valuable which Dr. Humphryf gives concerning the
removal of all tumors. "It is always well*' (he says) "to bear in mmd
that persons are most likely to consult us respecting these, or other
growths of the like kind, when they are out of health, and consequently
unfit to bear an operation : they do so because the tumor is then most
r productive of pain and annoyance.'*
A distressing instance of the truth of this occurred to myself several
years ago. A strong but very intemperate man came to me as an oat-
patient, with an ulcerated sebaceous cyst, about three-quarters of an
inch in diameter, just below and to the right of the umbilicus. He had
observed a tumor here for 16 years ; but he had scarcely thought of it
till, during the last five weeks, it had grown quickly, and in the \sst
fortnight had ulcerated. I saw no reason to be very cautious in such
a case ; so slit the tumor and removed it, as well as the thickening and
adhesion of the parts around would allow. In the evening, having
returned to his work and some intemperance, hemorrhage ensued from
a small cutaneous vessel, and before he reached the hospital he lost
more than a pint of blood. I tied the artery, and applied solution of
alum to the rest of the wound, for its whole surface was oozing blood,
and he was admitted into the hospital. The next day he became very
feverish, and he appeared as if he were going to have typhus, which
was then prevalent. But from this state he partially recovered ; and
then abscesses formed in his groins, and discharged profusely. Nothing
improved his health, and three months after the operation he died, ap-
parently exhausted by the continual discharge from the abscesses, and
with both external epigastric veins and parts of the femoral veins full
of old clotted blood — the consequence of slow phlebitis.
Cases like this, or ending fatally much sooner than this did, with
erysipelas or more acute phlebitis, have occurred to many surgeons.
They need no comment to make them instructive.
* College Museum, 157 a and 2297. A most remarkable specimen is in the Muscamof
Guy's Hospital, which was removed from an old man's thigh,
t Lectures on Surgery, p. 135; from the Provincial Medical and Surgical Journal.
DENTIGEROUS CYSTS. 895
I believe the contents thus protruded from cutaneous cysts may be-
come vascular. I have not seen this event, but it seemed certain in a
case observed by Mr. James Reid. A woman, 80 years old, had nume-
rous cysts in her scalp. They were like common sebaceous cysts ; and
three of her daughters had cysts like them. Two years and a half
before her death, one of the cysts, which had not previously appeared
different from the rest, inflamed. It was opened, and sebaceous matter
was discharged from it. The opening did not heal, but ulcerated, and
a small hard lump remained under the ulcer for a year, when, after
erysipelas of the head, it began to grow, and rather quickly increased
to a mass nearly five inche? in diameter, which occasionally bled largely.
The mass has the appearance of the firm contents of a cuticular and
sebaceous cyst, and contains abundant epidermal cells;* so that there
can be scarcely a doubt that it had its origih in the contents of such
a cyst.
6. Concerning cysts containing teeth, a few words must suffice. They
are of two kinds. Some, occurring in the ovaries, and more rarely in
other parts, bear, with one or more teeth, the products of skin, as hai?,
epidermis, &c.t These may be regarded as diseases of the same general
group with the cutaneous proliferous cysts ; and the great formative
power which they manifest is consistent with their occurring only in
embryonic or foetal life, and in the ovaries, in which, even indepen-
dently of impregnation, one discovers so many signs of great capacity
of development.
Other dentigerous cysts occur within the jaws. In some cases, cysts
are hollowed out in the substance of the upper or lower jaw, and are
lined with a distinct membrane, to some part of which a tooth is at-
tached. I believe these are examples of tooth-capsules, from which the
teeth, though perfectly formed, at least in their crowns, are not ex-
truded, and which therefore remain, becoming filled with fluid, and
growing larger.^ In other cases, that which appears as a cyst is the
antrum, distended with fluid, and having a tooth imbedded in some part
* Museum of St Bartholomew's Hospital, Series xxxv, No. 57. Probably the case was
similar which is related by Mr. Abernethy in his Essay on Tumors, p. 117. Such cases
b&Te peculiar interest in relation to the question of the possible origin of certain epithelial
cancers in these cysts. This will be referred to in Lecture xxxii.
f A very remarkable specimen is in the Museum of St. Bartholomew's Hospital (Mal-
formations, A 177). It was presented by Mr. Eingdon, and is described by Dr. Gordon in
the Med.-Chir. Trans., vol. xiii. In the anterior mediastinum of a woman twenty-one years
old, a tumor, probably of congenital origin, contained portions of skin and fat, serous fluid,
and tebaceous matter, and two pieces of bone like parts of upper jaws, in which seven
well-fbnned teeth were imbedded. In an ovarian tumor, more than 300 teeth were once
found : in another case, a piece of bone, like part of an upper jaw, with 44 teeth. See
Lang, in the essay cited below, p. 11.
X Two such cases are in the Museum of St Bartholomew's, Series i, 119, 119 a. I saw
a third cured by Mr. Wormald by cutting away part of the cyst, and removing the tooth.
896 FATTY TUMORS.
of its wall, and projecting into its cavity.* In the most remarkable
case of the kind, Professor Baum removed a tooth from each antrum of
a woman 38 years old. The distension of the antra, with excessive
thickening of their lining membranes, and thinning of their osseous
walls, and with accumulations of purulent fluid, had been in progress
for thirty years, and produced horrible deformity of the face. The
operation was completely curative.
LECTURE XXIV.
FATTY AND FIBRO-CBLLULAR TUMORS: PAINFUL SUBCUTANEOUS
TUMORS.
Among the solid tumors, the first that may be considered is the fatty
or adipose tumor, the Lipoma of some, the Steatoma of others ; the
most simple in its texture, the most like the natural parts, the least
liable to variations ; a morbid growth so well known, that I can scarcely
hope to impart any interest to an account of it.
Among the growths commonly included as fatty tumors, we find ex-
amples of both the forms of morbid hypertrophies of which I spoke in
the twenty-first lecture. There are both continuous and discontinuous
morbid hypertrophies of fat ; both fatty outgrowths and fatty tumors,
more properly so called, f
The Fatty Outgrowth is thus described by Sir B. C. Brodie, in his
well-known lecture upon fatty tumors. He says, — " There is no distinct
boundary to it, and you cannot say where the natural adipose structure
ends, and the morbid growth begins. . . . These tumors feel like fat,
but they may be distinguished from common fatty tumors by their
having no well-defined boundary, and by their being less soft and
elastic. Such deposits may take place in any part of the body ; but I
have seen them more frequently in the neck than anywhere else."|
Doubtless the case will be familiar to you by which Sir B. C. Brodie il-
lustrates this account, — the case of a footman, with an enormous double
chin, and a great mass of fat extending from ear to ear, who was cured
by the liquor potassce. The case already cited from Schuh's essay (p*
340), was of the same kind.
I can add nothing to this account, except the mention of a singular
* The principal cases are collected in two essays, for which I have to thank Professor
Baum; namely, Lang, Ueber das Yorkommen von Zahnen im Sinus maxillare; Tiibingent
1844; and Glasewald, De Tumore quodam utriusque Antri Highmori : Gryphia;, 1844.
Three good cases, also, are related by Mr. Sailer in the Guy's Hospital Reports for 1859.
f M. Lebert (Abhandlungen, p. 112) distinguishes the fatty tumors, according to their
degrees of isolation, as Lipoma circumscriptum and L. difiusum.
X Lectures on Pathology and Surgery, p. 275.
FATTY TUMORS. 397
case of fatty growth connected with the heart of a sheep.* The right
yentricle is nearly filled with a lobnlated mass of fat, distending it, and
pressing back the tricuspid valve. The left auricle and ventricle are
similarly nearly filled with fatty growths, and fat is accumulated on the
exterior of the heart, adding altogether about twenty-five ounces to its
weight. The textures of the heart itself appear healthy, though it is
the seat of all these fatty growths.
The discontinuous Fatty Tumors, of which alone I shall now speak,
present a tissue exactly or very nearly resembling the normal fatty or
adipose tissue of the animal in which they grow. Certain differences
may, indeed, be sometimes found between the fat of a tumor and that
of the part in which it lies; such as the larger size of the tumor's cells,
its less or greater firmness at the same temperature, and the usual crys-
tallizing of the margarine ; but I believe there are no greater differ-
ences than may be found in the natural fat of different parts of the
same person.
It would be superfluous to describe or delineate the minute characters
of this well-known tissue : it is only in its arrangement that the tumors
have any peculiarity worth notice. It is, in all, composed essentially
of clustered oil-cells ; but these are, in some tumors, placed in a uni-
form mass, smooth on its surface, and only obscurely partitioned ; in
others, arranged in oval or pyriform lobes, projecting on the surface,
easily separable by splitting their connective-tissue partitions ; and in
some of these it may be dissected into thin layers, which are wrapped
in each lobe, one within the other, like the leaflets of a bud. Moreover,
any of these forms, whether "simple," or " lobed," or "involuted,'*
may be either deeply imbedded in the tissues, or " pendulous."
Fatty tumors are, I believe, always invested with a capsule, or cover-
ing of connective tissue ; and of these capsules, since they exist with
most of the innocent tumors, I may speak now once for all. The cap-
sule, then, of such a tumor is usually a layer of fibro-cellular, areolar,
or connective tissue, well-organized, dry, and containing bloodvessels
proportioned to the size of the tumor. It appears to be formed of the
connective tissue of the part in which the tumor grows, increased, and
often strengthened, in adaptation to the bulk and other conditions of
what it incloses. It grows with the tumor, invests it, and at once con-
nects it with the adjacent tissues, and separates it from them ; just as,
e. ff-j similar connective tissue does each muscle in a limb. Its adhesion
to both the tumor and the parts around it is more intimate than that
of its layers or portions to one another ; so that when such a tumor is
cut into, it may be dislodged by splitting its capsule, and leaving some
of it on the tumor, and some in the cavity from which the tumor is ex-
tracted. This, at least, can be easily done unless the tumor has been
the seat of inflammation, which may thicken the capsule and make all
* iMu8. Coll. Surg., 1529.
398 FATTY TUMORS.
its parts adherent to one another, and to the tissues on either side of it.
As Schuh observes, when a fatty tumor is just under the skin its cap-
sule is usually more closely connected with the skin in the interspaces
between the lobes than in any other part, so that the skin appears
dimpled over it, especially if one squeezes the tumor at its base, and
presses it up to make the skin tense.
In the capsule, the bloodvessels that supply the tumor usually first
ramify. One principal artery, indeed, commonly, but not always,
passes straightway into the tumor at its deepest part, but the rest
branch in the capsule, especially in any thicker parts of it that lie in
the spaces between projecting lobes of the tumor. Hence, with the
partitions of the tumor that are derived from the capsule, the blood-
vessels pass into its substance.
The capsules of these fatty tumors may vary somewhat in thickness
and toughness ; and so may the partitions that proceed from them into
the mass. They are usually very delicate ; but they are sometimes
thick and strong, and give a density and toughness which approa<;h to
the characters of a fibrous tumor. To such examples of fatty tumors
deviating from the common type, Mliller* has assigned the name of
Lipoma mixtum; and Vogel,t Gluge,J Rokitan8ky,§ and some others,
call them "steatoma," and "lardaceous tumor*' (Speckgeschwul8t).||
Fatty tumors usually occur singly ; but there are many exceptions
to this rule. Two or three in the same person are not rarely seen, and
a hundred or more may exist. Sir B. C. Brodie mentions such cases ;
and I am acquainted with a gentleman, who has borne, for nearly twenty
years, firm tumors, feeling like fatty masses, in the subcutaneous tissue
of his trunk and all his limbs. They are usually stationary, but some-
times one grows a little, or one diminishes, or a new one appears.
Lately, I have seen a woman, 50 years old, in whom a large number of
similar tumors had been growing for about ten years in the subcuta-
neous tissue of the arms, thighs, and haunches. They were all small
and firm, and felt like tumors of mixed fatty and tough connective
tissue.
The most frequent seats of fatty tumors are the trunk, and the part
of the neck and limbs that are nearest to it ; but they may occur in
any part where fat naturally exists, and they are not limited even to
these. T[ It is, perhaps, impossible to say why they should affect one
* On Cancer, p. 153. f Pathologische Anatomic, p. 179.
J Pathologische Anatomie. § Pathologisrhe Anatomic, B. i, p. 283.
II MQllcr also gives the name of Lipoma arborescens to the pendulous fatty processes
with synovial membrane that are clustercH about chronic diseased joints. Sir B. C. Brodie
(Lectures, I. c.) describes a form of fatty tumor, which I have not yet seen, in which the
tumor is covered with a double layer of membrane, like a serous sac.
1[ Moller (On Cancer, p. 153) describes one between the optic nerves and corpora alhi*
cantia ; and Rokitansky (B, i, p. 282), including both the tutnors and the outgrowths, refers
to examples of Lipoma in the submucous tissue of the stomach, intestines, and bronchi; io
the subserous tissue of the pleura, peritoneum, dura mater, and cerebral ventricles ; and in
PATTY TUMORS. 399
locality of fat rather than another. Their rarity in the human mesen-
tery and omentum, and the fat about the internal organs, is remarkable.
I have never seen one in the recent state in any of these parts ; and I
know only two or three specimens in museums.* In the College Mu-
seum (No. 194) is a bilobed mass of fat, inclosed in a thick capsule,
and attached by a long pedicle to the intestine of an ox. In the trunk
and limbs, they appear less frequent in the parts in which the natural
fat, though abundant, is subject to least variations in its quantity ; such
as the palms and 8oles,t and the bones ; and they are rarely, if ever,
formed in parts of or near the trunk where very little fat naturally
exists, as the eyelids^ and the greater part of the scrotum. Fatty
tumors have, indeed, been found in the scrotum ; § and one very re-
markable case is related by Mr. Lawrence and Sir B. C. Brodie : but,
perhaps, such tumors have not begun to grow in the part in which they
were at length found ; they may have grown or shifted into it.
This shifting of fatty tumors is worth notice ; for the fact may be
used in the diagnosis of them when they occur in the groin or scrotum,
or other unusual place.
A patient was under Mr. Lloyd's care, in St. Bartholomew's Hos-
pital, with a strange-looking pendulous fatty tumor in the perineum.
It hong like a pocket-flask between his scrotum and thigh ; but he was
quite clear that it was in his groin ten years before, and that it had
gradually shifted downwards. It was removed, and no pedicle or other
trace of it remained in the groin.
I find, also, a case by Mr. Lyford,|| in which a large fatty tumor be-
gan to grow in the abdominal wall, midway between the spine of the
ilium and the pubes, and thence, as it increased, gradually moved down-
wards, and was excised from the upper and inner part of the thigh.
And thus, in Mr. Lawrence's case, the tumor began to grow in the
the longs, liver, and kidneys. A very remarkable case of pendulous fatty tumor of the
pharynx and larynx is related by Mr. Holt. Trans. Pathol. Soc., vol. v, p 123.
* One, referred to in Lecture xxi, is in the Museum of St. George's Hospital. Other
cases are related by Vogel (Path. Anat., tab. xxii, Fig. 1); Gluge (I. c. Lief viii) ; Lebert
(Phys. Pathol., ii, p. 105). They are not rare in the corresponding parts of horses and other
domestic mammalia. (FOrstenburg : Die FettgeschwQlste und ihrer Metamorphose; Berlin,
1851.) The editor found, on one occasion, a well-marked fatty tumor, the size of a large
walnut, growing in the submucous tissue of the large intestine, and projecting into the cavity
of the gut at the angle of junction of the two segments of the ileo-coecal valve, which were,
in consequence, much displaced.
f M. FoUin has related (C. R. de la Soc. de Biologic, t. iv, p. 71) a case of a fatty tumor
as large as a pullet's egg on the anterior and external aspect of the middle finger of a man
about fifty years old. It adhered tirmly to the sheath of the tendon, which was opened in
removing it. In the St. Bartholomew's Hospital Museum there is now a specimen of a fatty
tumor from the palm.
^ Cases of fatty tumors in or encroaching on the orbit, are recorded by Mr. Hutchinson
in the Med. Times and Graz, December 16, 1853.
{ Gluge mentions one in the labium of a woman seventy years old. It was pyriform, and
locked like a hernia (Path* Anat., Lief viii, Taf i, Fig. 1).
I Med. Ottz., iv, 348.
400 FATTY TUMORS.
spermatic cord, and thence had partly extended and partly shifted into
the scrotum behind the testicle, where it was extremely difficult to de-
cide its nature. For in the layer of fat outside the peritoneum small
fatty tumors (hernie graisseuse) not unfrequently grow, which may ex-
tend along with the cord, down the inguinal canal, and in their position,
at least, simulate that of an inguinal hernia.
The fatty tumors usually lie in the subcutaneous tissue, extending in
it between the skin and the deeper fascia : but they may extend more
deeply. Mr. Wormald removed one, from which distinct lobes or pro-
longations passed between the fasciculi of the trapezius muscle, and,
expanding below them, were constricted by them. In the case of a
great fatty tumor* of the neck, removed by Mr. Listen, the operation
was made formidable by the lobes of fat extending deeply to the trachea
and oesophagus. In rare cases, fatty tumors may be altogether deeply
seated : I found one resting on the lesser trochanter of the femur, grow-
ing up by the side of the pectineus muscle, but not prominent externally.
Vogel mentions the case of a woman who had several fatty tumors, one
of which was so closely connected with the nasal bone and the nasal
process of the superior maxillary bone, that it was necessary to remove
these with it. Mr. Abernethy also refers to a fatty tumor, removed
by Mr. Cline, which adhered to the capsule of the hip joint.f In the
Museum of the Middlesex Hospital is a fatty tumor one and a half
inches long, which was removed from beneath the tongue, where it
looked like a ranula ; in the College MuseumJ is one taken from the
substance of the tongue ; and Virchow has related§ a case of numerous
fatty tumors occurring in the nerves and other parts.
Such are some of the chief facts respecting the structure of this kind
of tumors. Of their life, I need say little.
Their development is, probably, like that of the natural fat, and in
them, according to C. 0. Weber, || the gradual production of fat-cells
out of connective-tissue corpuscles may be traced.
Their growth is usually slow, and without pain or any affection of
the adjacent parts ; but they often grow capriciously, having uncertain
periods of acceleration and arrest, of which no explanation can be given.
The extent of growth cannot well be measured ; for fatty tumors have
been cut out that weighed between fifty and sixty pounds, and such as
these, after twenty, or even fifty years, were still growing, and might
have continued to do so as long as the patient lived. I believe the
largest in London is that in the Museum of St. Thomas's Hospital,
which was removed from a man's abdomen by Sir Astley Cooper, and
weighed 37 lbs. 10 oz.T[ One of the most formidable is that in the Col-
lege Museum, removed by Mr. Liston from a man's neck,** where it had
* Mus. Coll. Surg., No. 190.
■f See also BrocUe, 1. c. ; Simon, Lectures on Pathology ; and others.
X No. 1065. § Archiv, B. xi, H. iii, p. 281, 1857.
II Virchow's Archiv, B. xv, p. CI, 1859. ][ Medico-Chirurg. Trans., vol. ix, p. 440.
♦♦ No. 190.
FATTY TUMORS. 401
been growing for twenty-two years; A parallel to it is drawn in the
splendid work of An vert.*
What degenerations the fatty tumors may be liable to are not known ;
their diseases have some points of interest.
They may be partially indurated. The chief mass of a tumor may
be found with the characteristic softness, pliancy, and inelasticity of
fat ; but in its substance one or more lumps, like hard knots, may be
imbedded. So far as I have seen, these depend on induration, contrac-
tion, and a proportionate increase, of the connective tissue of the fat ;
and the change is probably due to slow inflammation of the tumor. It
may be sometimes traced to frequent pressure. A laundress had a fatty
tumor, as large as a foetal head, above her ilium, and portions of it were
as hard to the touch as cartilage, and appeared to move so freely in the
soft fat-tissue about them, one might have thought them loose bodies,
or fluid within cysts. Where these were, the patient had been in the
habit of resting her linen basket.
The indurated parts of a fatty tumor may be the seats of bone-like
formations. This is, I believe, very rare ; and I have seen only the
single specimen in the Museum of St. Bartholomew's Hospital rf but
Auvert describes the same change.f
Cysts, also, may form in fatty tumors. In the case with partial in-
durations just mentioned, I found, in another part of the tumor, a cyst
with thin and partially calcified walls, which contained a glutinous and
greenish oily fluid. I presume it is to tumors of this kind that Gluge
gives the name of Lipoma colloides.
Suppuration and sloughing may occur in these tumors : but they are
on the whole very rare events, except in large pendulous tumors, which
have grown too large to be effectively nourished through their bases of
attachment. Pathologically these changes have little interest ; but in
practice they are more important, as being almost the only way in which
external fatty tumors are likely to lead to death. Even in these cases,
however, they show no real imitation of malignant disease.§ I once,
indeed, saw a case in which the end of a pendulous fatty tumor in a
toman's perineum was so ulcerated that it looked like cancerous dis-
ease : but after a week's rest in bed, during which the patient menstru-
ated; it lost its malignant aspect. It now acquired (what the ulcers
over and in fatty tumors commonly present) clean, inverted and over-
hanging, wedge-shaped, granulating edges.
* Ob«. Med.-Cbir , Tab. li. See for a list of the largest elsewhere recorded, Mr. South's
^ition of Cbelius's Surgery, ii, pp. 691-2. In the Cleveland (U. S.) Medical Gazette, Au-
Kast, 1859, is an account of a" Mammoth Tumor'* of the abdomen and hip by Dr. Delama-
ter. It appears to have been composed chiefly of fat, and was estimated at 275 lbs. weight.
t Ser. XXXV, 11.
J Tab. xvi. A case also by Mr. T. Smith in the Trans. Pathol. Soc., vol. ix, p. 384.
$ On the possible conjunction of fatty tumors and malignant disease, see Sir B. C. Bro-
die's Lectures, p. 282 ; and the same on the combination of fatty and mammary glandular
to mora.
402 FIBRO-OELLULAR TUMORS.
Lastly, respecting the causes of these tumors few things can be more
obscure. Nearly all knowledge on this point is negative. The growth
may have followed an injury, and we may call this the cause of its for-
mation ; but we can give no explanation why such an event as an injury,
which usually produces only a transitory impairment of nutrition, or a
trivial inflammation, should, in these cases, give rise to the production
of a new and constantly growing mass of fat.
FiBRO-CBLLULAR TUMORS.
Under this name I propose to cpnsider the tumors which, in their
minute structure and their general aspect, resemble the fibro-cellular,
areolar, or looser form of connective tissue of the body. So far as I
know, no general account of them is published. The first distinction of
them was made, I believe, by Mr. Lawrence,* who described an admi-
rable example in his paper on Tumors : and they are briefly but accu-
rately described by Mr. Caesar HawkinSjf as a softer and more elastic
form of the fibrous tumor. Miiller,J also, refers to them by the name of
Cellulo-fibrous tumor ; Vogel,§ by that of Connective tissue tumor
(Bindegewebgeschwlilste), comparing their tissue with that of the cutis;
and Rokitanskyll points to them as a variety of ^'gelatinous sarcoma."
But these passing references have not obtained for this kind of tumor a
general recognition, and in many works it is altogether overlooked.
As in the last kind, so in this, we find instances of both outgrowths
and tumors ; i. e, of both continuous and discontinuous overgrowths.
The former are, indeed, abundant and often described ; for among them,
as being formed chiefly of overgrowing fibro-cellular tissue, are the
most frequent forms of polypi of mucous membranes, and of hypertro-
phies of skin or cutaneous outgrowths.
1. Nearly all the softer kinds of polypi, growing from mucous mem-
branes, consist of rudimental or more nearly perfect fibro-cellular
* Meilico-Chirorg. Trans., vol. xvii, p. 14. t Medical Gazette, vol. xxi, p. 9'25.
X On Cancer, p. 14. § Pathologische Anatomie, p. 185.
II Path. Anat., i, p. 336. Mflller and others describe, under the name of " Collonema,*' ■
tumor such as I have not seen unless it be an example of very soft tibro-cellular tumor.
Rokitansky (i, 335) describes it as a very soft, tolerably clear, flickering substance, like gela-
tine, of grayish-yellow color. He briefly describes four specimens observed by himself.
Bruch describes as a genuine example of Collonema what I can scarcely doubt was a very
soft fibro-cellular tumor. (Ueber Carcinoma alveolare ; in Henle and Pfeufer's Zeitschrift,
1849, p. 356.) A description of Collonema by Wagner (Virchow's Archiv, viii, p. 23"2) con-
firms this opinion. Virchow, also, regards these cases of Collonema as nothing more than
tumors formed of very soft connective tissue soaked in an albuminous fluid (Cellular Patbo*
logic, Lecture XX); and Billroth (Entwick. der Blutgefasse, p. 44), states that a Collonerat
is a connective tissue tumor of a gelatinous consistence, the fibres of which are of extreme
delicacy. Virchow has also described under the name of Schleim-geschwQlste, Myxomatt,
mucous tumors, a set of tumors which correspond in their structure to that most delicate of
all the forms of connective tissue, which constitutes the tissue of the vitreous body, Whar
tonian jelly of the umbilical cord, and the subcutaneous tissue of the embryo, and which be
names mucous tissue.
FIBBO-CELLULAR POLYPI. 408
tissue, made succulent by serous or synovia-like fluid infiltrated in its
meshes : the firmer kinds of polypi are formed of a tougher, more com-
pact, drier, and more fibrous or fascia-like tissue. Of the softer kind,
the best examples are the common polypi of the nose : mucous, gela-
tinous, or vesicular polypi, as they have been called. These are pale,
pellucid, or opaque-whitish, pendulous outgrowths of the mucous mem-
brane of the nose, — most frequently of that which covers the middle of
its outer wall. They are soft and easily crushed, and in their growth
they adapt themselves to the shape of the nasal cavity, or, when of
large size, project beyond it into the pharynx, or, more rarely, dilate
it. As they increase in size, so, in general, does the part by which
they are continuous with the natural or slightly thickened membrane
become comparatively thinner, or flatter : their surfaces <nay be simple
and smooth, or lobed ; they often hang in clusters, and thus make up
a great mass, though none of them singly may be large. A clear ropy
fluid is diffused through the substance of such polypi, and the quantity
of this fluid, which is generally enough to make them soft and hyaline,
appear^ to be increased when evaporation is hindered ; for in damp
weather the polypi are always larger. Bloodvessels enter their bases,
and ramify with wide-extending branches through their substance,
accompanying usually the larger and more opaque bundles of fibro-
cellular tissue. Cysts full of synovia-like fluid sometimes exist within
them.
To the microscopic examination these polypi present delicate fibro-
cellular tissue, in fine undulating and interlacing bundles of filaments.
In the interstitial liquid or half-liquid substance, nucleated cells ap-
pear, imbedded in a clear or dimly granular substance ; and these cells
may be spherical, or elongated, or stellate ; imitating all the forms of
Buch as occur in the natural embryonic fibro-cellular tissue : or, the
mass may be more completely formed of fibro-cellular tissue, in which,
on adding acetic acid, abundant nuclei appear. In general, the firmer
the polypus is, the more perfect, as well as the more abundant, is the
fibro-cellular tissue. The surface is covered with ciliary epithelium
exactly similar to that which invests the healthy nasal mucous mem-
brane, and supplies the most convenient specimens for the examination
of active ciliary movement in human tissues.*
The soft polypi that grow, very rarely, in the antrum, and other
* An excellent essay on the structure of mucous polypi "«Ueber den Bau der Schleim-
polypen" has been published by Dr. Th. Billroth, Berlin, 1855, from which the above
detcription of the structure of the nasal polypi may be supplemented with a few additional
iMirticuIars. He states that on one occasion he has seen nerve-fibres in a nasal mucous
polypus, bat their mode of termination he could not determine. He has also found, as
m^bt naturally be expected, the mucous membrane on the surface of these polypi to be
glandular; but in addition, especially in the larger polypi, he has observed the substance
fsi the polypus to a great extent made up of gland structures, generally like the natural
ghindt crf'tbe nasal mucous membrane, but sometimes modified in shape.
404 FIBKO-CELLULAR POLYPI.
cavities communicating with the nose, are, I believe, just like these.*
And those of the external auditory passage are, in structure, not essen-
tially different. All that I have been able to examine appeared com-
posed of rudimental fibro-cellular tissue ^f but they are generally more
vascular, firmer, and less succulent than the nasal mucous polypi ; they
are also much more prone to inflammation and to superficial ulceration,
perhaps through being so often connected with disease of the tympanum
or its membrane. The mucous polypi of the uterus are also, I believe,
like those of the nose.
A large, deeply lobed, soft, and nearly clear polypus in the urinary
bladder, the only specimen I have seen in the recent state,J was com-
posed, in part, of very fine filamentous fibro-cellular tissue, and, in
greater part, of granular or dim homogeneous substance, with imbedded
nuclei. Over the substance which these formed, there was an immense
quantity of tessellated epithelium, with large scales, like those of the
epithelium of the mouth : indeed, so abundant was this, that it formed
the chief constituent of the smaller lobes of the polypus. Once, also,
I have been able to examine a polypus of the rectum, which, being soft
and succulent, might have been classed with these ; but it was composed
almost entirely of gland-textures. It was like a disorderly mass of
such tubular glands, lined with cylindriform epithelium, as are found
in the mucous membrane of the rectum. These were heaped together
with some intersecting fibro-cellular tissue, and with abundant viscid
fluid-like synovia or thin mucus. The polypus was spheroidal, about
two-thirds of an inch in diameter, and attached by a pedicle nearly an
inch long to the anterior wall of the rectum : it received so abundant a
supply of blood through the pedicle, that I think excision would have
been very unsafe, unless I had first tied the base of the pedicle.§
* See Schuh, Pseudoplasmen, p. vr). Billroth (p. 11) describes and figures a good in-
stance of polypus of the antrum, which he considers to be a very rare affection. But
Luschka (Virchow's Archiv, B. iv, p. 410, 1850), states that these polypi are not so rare M
is usually supposed. He has found them five times in about sixty bodies examined. H«
considers them to be hypertrophies of the submucous connective tissue covered with tb«
mucous membrane. Forster has given beautiful figures illustrating the structure of a poly-
pus from the antrum, in pi. 25 of his Atlas.
f M. Lebert says the specimens he has observed were composed of fibro-plastic tissue.
Professor Bnum tells me he has generally found the surfaces of aural as well as of naai
polypi covered with ciliary epithelium. Meissner, Billroth, Forster, and the editor, have
also seen ciliated epithelium on the surface of aural polypi, and both Billroth and Forster
(Atlas, Taf. xxxv), have found distinct and tolerably large papilla; on them.
J It is in the Museum of Si. BatthoIomews,and iH described by Mr. Savory in the Medi-
cal Times, July 31, 1852. Mr. Birkett has, in Trans. Med. Chi. Soc., vol. xli, 1858, described
a polypus of the bladder which "resembled in every anatomical particular the succulent
fibrous growth termed nasal polypus."
§ Other cases of mucous and glandular polypi of the rectum may be found recorded by
M. Forget in the Union Medicale, June 21, 1853 : by Harpeck in a pamphlet "De jwlypis
recti," 1855; by Forster in his Atlas, Taf xxv, and by Billroth in the essay already quoted.
The last-named observer has also described cases of mucous polypi of the larynx and tra-
chea, of the female urethra and of the uterus. He refers also to two cases of mucous polypus
of the lacrymal sac.
CUTANEOUS OUTGROWTHS. 405
2. The best examples of Cutaneous Outgrowths, of which, as I
have said, a second division of the fibro-cellular outgrowths is com-
posed, are those which occur in the scrotum, prepuce, labia, nymphse,
clitoris and its prepuce.* These, which reach their maximum of growth
in the huge ^^elephantiasis scroti" of tropical countries, consist mainly
of overgrowing fibro-cellular tissue, which, mingled with elastic tissue,
and with more or less fat, imitates in general structure the outer com-
pact layer of the cutis. Their tissue is always closely woven, very
tough, and elastic ; in some eases it is compressible and succulent, as
if anasarcous, and it yields, on section, a large quantity of serous-look-
ing fluid ; in others, it is much denser, interlaced with strong, shining
bands, like those of a fascia ; in others, it is meshed with intervening
lobes of fat ; and in others, is uniformly solid and glistening, yellowish,
or with an ochre tinge, like udder. The minute textures are, however,
I believe, essentially the same among these diversities of general aspect ;
they are, in various proportions, the usual textures of the cutis and sub-
cutaneous tissue, excepting (so far at least as present observation ex-
tends) the smooth muscular fibres. The diversities of external form
are more numerous. In some, as, most commonly, on the nymphse and
prepuce of the clitoris, the masses are suspended by comparatively
narrow pedicles ; thus, also, are suspended most of the small cutaneous
outgrowths that are common on the trunk and limbs ; in some the bases
are very broad, as in the nose, in which, moreover, the growth of skin
is generally associated with acne and dilatation of its minute blood-
vessels ; in some, as in the elephantiasis scroti, a large extent of skin
appears uniformly affected. Again, in different instances, they are
lobed, or less deeply subdivided, or smooth or warty on their surfaces ;
healthy or darkened epidermis covers them ; and the sebaceous glands
and hair-follicles sinking beneath their surfaces, as in the healthy skin,
are not unfrequently considerably enlarged. In the elephantiasis of
the extremities and of the scrotum, not only the* isolation, but even the
circumscribed appearance, of a tumor is lost ; the affection is classed
with the diseases of the skin rather than with tumors, and, in morbid
anatomy, is, perhaps, not to be distinguished from the consequences of
chronic or repeated inflammations of the integuments. In all cases,
however, let the external form be what it may, there is such uninter-
rupted continuity between the several tissues of the overgrowth and
Poljrpi of the Tagina should also be classed along with the above, as examples of mucous
poljrpi* Sir C. Locock has stated that he had of\en seen a single little mucous polypus at-
tached to a nympba, or some part of the wall of the vagina in children, either at birth, or
in later life.
* I suppose that the disease named Molluscum simplex should be classed with these : but
I have never seen a good instance of it. The best accounts that I have read are by G.
Simon: "Die Hautkrankbeiten," pp. 50 and 219, and Jacobovics ; Du Molluscum. Another
fbrofi oC disease sometimes thus named consists in morbid changes of very numerous hair-
Iblliclea. See a case by Dr. Beale in Trans. Pathol. Soc., vi, 313.
406 FIBRO-CELLULAR TUMORS.
those of the healthy cutis, that the disease might be taken as the type
of the "continuous overgrowths.***
FiBRO-OBLLULAR TuMORS, properly so called, are much rarer than
the outgrowths of the same texture which I "have just described. They
are also rare in comparison with other tumors ; and this is singular,
considering the abundance of the fibro-cellular tissue naturally existing,
its general diffusion, its easy formation after injuries, in disease, and
even in and about other tumors. I can in no wise explain the fact ; but
it is certain that for ten tumors formed of fat or cartilage (tissues which
are rarely produced in other diseases), we do not find more than one
formed of fibro-cellular tissue.
The form in which the fibro-cellular tumors are most frequently seen
is that of oval or round masses of soft, elastic, close, and pliant tissues,
smooth and uniform, or, when they grow among yielding parts, deeply
and variously lobed. Their exterior surface is connected with the ad-
jacent parts by a capsule of connective tissue, which generally splits
readily. When handled they feel peculiarly tense and elastic ; ,their
outer surface may shine like a thin sac full of fluid. On their sections
we see opaque white bands, intersecting a shining succulent basis-sub-
stance of serous yellow or greenish yellow tint. Through this basis
the bands course in circles or wavy lines, or form complete partitions;
or, in the smaller lobes of the tumor, they run without order, only
forming white marks on the yellow ground-color, but giving no appea^
ance of grain, or of regularly fibrous structure.
The peculiar yellow color of the basis-substance of these tumors
makes them look at first like fat ; it is due, however, not to fat, but to
a serous, or synovia-like, or very viscid, fluid, which is infiltrated through
the substance of the tumor. The mass is just like anasarcous areolar
tissue ; most of all like the subcutaneous areolar tissue of the back, as
one sees it dissected in a dropsical body. When such a tumor is cut
through or sliced, the clear yellow fluid oozes from it, or may be abun-
* Well-marked specimens of cutaneous outgrowths are in the Museum of the Colleg0i
Nos. 2283 to 2290, 240r)-.7, 2708 to 2714 j and in that of St. Bartholomew's, Ser. xi, 18, l9;
Ser. xxviii, 18; and Ser. xxxii, 36, 37. I lately cut one from a man's nates (a very un-
usual place of growth), which weighed upwards of eight pounds. It had been growing
for twenty years, and formed a great pendulous mass, on which he used to sit : its bsw
covered the whole region of the glutei muscles. As examples of cutaneous outgrowths,
ought also to be enumerated those cases of a peculiar form of tumor of the skin which Pro-
fessor Valentine Mott has described by the name of " Pachydermatocele" in the Med. Chi.
Trans., vol. xxxvii, 1854. Of the five cases recorded, one returned twice aAer remowl*
Other cases of cutaneous outgrowths are recorded by Mr. O. Pemberton in Med. Times and
Gaz., July, 1856.
With the cutaneous outgrowths ought perhaps to be included those curious cases which
constitute the Keloid of Alibert, and which appear to consist of a fibrous development in
the subcutaneous areolar tissue. Fuller information on this subject may be found in Di^
berg's pamphlet '*De Tumoribus Celoidibus," Dorpat, 1852, and in a paper by Dr. Addison
in Trans. Med. Chi. Soc., vol. xxxvii, 1854.
FIBRO-CBLLULAR TUMORS.
407
dantly pressed out ; in alcohol the same fluid coagulates ; in both cases,
the filamentous tissue contracting, becomes denser and more compact,
and more uniformly opaque white, like that of the softer varieties of
fibrous tumor. It is to these last-named tumors, indeed, that the
fibro-cellular have the nearest relations, and into them that they ''pass*'
through gradational specimens ; but there is just the same difi'erence,
as well as just the same relation, between these kinds of tumors, as there
is between the natural fibro-cellular and fibrous tissues ; and there is
a similar propriety in distinguishing them.
Examined with the microscope, the fibro-cellular tumors display the
filamentous tissue or appearance characteristic of that after which they
are named. In many cases, or in many parts, parallel, soft, undula-
ting filaments are
found collected in Fig. 62. »
fasciculi, which in-
terlace, and from
which single fila-
.ments can often be
traced out (Fig. 52);
or, where this is
not seen, the tex-
ture looks filament-
ous, through mark-
ings or wrinkles of
the surface of a
more homogeneous
substance. The
best developed and
most filamentous tissue is in the intersecting white bands : but similar
tissue is usually present everywhere. In many instances abundant
nuclei appear among the filaments, or imbedded in the more homoge-
neous substance, and acetic acid rarely fails to bring into view such
nuclei in crowds. In many, also, cells like those of granulations, and
others elongated and attenuated, appear as if in process of development
into filaments.
The homology of these tumors, in respect of tissue, is thus as perfect
as that of the fatty tumors. In chemical analysis they may yield
gelatine from thie well-formed fibro-cellular tissue ; but I believe they
yield much more albuminous matter from their imperfectly developed
tissue, and from the serous fluid that is soaked in them.
In general, there is nearly complete uniformity through the whole
mass of one of these tumors. Oftentimes, however, different portions
are more or less oedematous (if I may so call them) ; and, which is more
.^
5
v.vrf^S^l
* Bficroscopic elements of a fibro-cellular tumor, with cells in various stages of elongation
and attenuation. Magnified about 450 times.
remarkable, portions of cartilage, sometiinea partially ossified, may be
found in or over them. I have thrice eeen this. In the first case
nodules of cartilage were iiu-
F'g' ^3* bedded in a fibro-cellalar lu-
^,"'-.-.v^v^>^ mor that grew in the ball of
^* , "^ the great toe ; in the second
(a similar tumor from the
thigh) (Fig. 53), a portion of
. its surface, and one of its chief
) partitions, were formed with
I cartilage partially ossified ; in
' the third, a similar tumor from
the thigh was thinly, but com-
pletely, encased with hone.t
Moreover, besides these differ-
ences dependent on mixtures
of other tissues with those
proper to the tumors, some
may be found which are duo
to parts of the tumor being immature or imperfectly developed, anil
from this imperfect state degenerate. I have lately seen two such spe-
cimens, of which one was removed from the inner and deeper part of »
gentleman's ham by Mr. Lawrence ; and the other, seated between llm
superficial and deep muscles of a woman's fore-arm, was removed b^
Mr. Gay. The former was of three years', the latter of two years',
growth. Both were of oval form, deeply lobed, very soft, loosely con-
nected by a thin capsule with the ailjacent healthy parts, and abonl
eight inches in chief diameter. Partitions, proceeding from the capsule,
and including largo bloodvessels, intersected the tumors, which were
mainly composed of a bright serous-yellow, flickering, but tenscioas
substauce, half pellucid, like siiie-gelatine. Opaque white lines travers-
ing this substance, gave it the general appearance of the softest and most
succulent fibro-cellular tumors, or of the common mucous polypus of the
nose.
These characters, which were common to large portions of bolli
tumors, were, however, in some lobes of each, widely deviated from. In
the tumor from the ham, some lobes were suffused and traced over with
bright crimson and vermilion tints, and looked like lumps of sixc uml
vermilion ill-mixed for an injection. Other lobes had patches of buff-
colored or oclirey soft shreddy substance, or consisted almost wholly of
such a substance. In the tumor in the fore-arm there was less appear-
ance of vascularity, but the ochrey substance was more abundant, auJ
• Section of a flbrfHSellulat Iiimor intetserlod will] corliUge and pBriiully enciuKl *iili
bone: reJucsd on»UaJr. Dsscribeil above, anit p. 413.
t All iheae specimena are in Ihe Museum of Si. BarLlmlomew'a Haspiial.
FIBRO-OELLULAR TUMORS. 409
parts of some lobes seemed liquefied in a turbid thick fluid of ochre or
buff-yellow tint. In other portions it had a greenish-yellow hue, as if
infiltrated with dried-up pus; in others, it was nearly white and brain-
like ; in others, it had mingled shades of pink and gray. But various
as were the aspects of these tumors, so that with the naked eye it would
have been extremely difiicult or impossible to discern their kind, yet,
in all parts, they showed microscopic structures characteristic of the
fibro-cellular tissue in an immature state. Serous or synovia-like fluid
oozed from them, but none that was pulpy or cream-like. The serous
colored parts consisted mainly of well-formed fibro-cellular tissue, or of
a clear imperfectly fibrillated blastema, with closely imbedded corpus-
cles, like nuclei. Many of these corpuscles were clear, but many were
granular, as if with fatty degeneration, or appeared changed into small
granule-masses. In the bufi* and ochre-colored parts, similar tissue or
blastema was sprinkled over, or was quite obscured, with minute shin-
ing black-edged molecules, like oil particles, and with drops of oil. In
other parts, some nuclei appeared like those of very soft cartilage ; in
others crystals of cholesterine were mingled with the oily matter. In
the greenish-yellow parts, also, were corpuscles, like shrivelled pus-cells,
mixed with fatty particles and debris ; and, again, in other parts, cells
elongated like those of granulations.
No specimens could illustrate better than such as these the necessity
of learning, as I have already said, to distinguish, in each tumor, the
exceeding varieties presented in the phases of development of prema-
ture degeneration and of disease.
The most frequent seats of fibro-cellular tumors appear to be the
scrotum, the labium or the tissues by the side of the vagina, and the
deep-seated intermuscular spaces in the thigh and arm. They may
occur, probably, in many other parts; but either they particularly
affect these, or else a singular chance has shown them to me in these
situations with unusual frequency.
In the scrotum I have been able to examine two cases, and have
found records or notices of many more. The first case is represented
in a large specimen in the Museum of St. Bartholomew's, and in a
drawing made shortly after the parts were removed. The patient was
a carpenter, 74 years old ; and, when he was under Mr. Stanley's care,
the tumor had existed four years. It was a huge mass, about a foot
long, and six or seven inches wide, filling the scrotum, and drawing over
it all the adjacent integuments. A collection of fiuid, like a hydrocele,
was at its lower part, a large hernial sac was above it, and the scrotum
was thick and cedematous. The obscurities these complications threw
upon the diagnosis of the tumor, the doubt how far the hernial sac might
extend, the patient's age, and his aversion from any operation, were
sufficient to dissuade from active interference.
The patient died about half a year after leaving the hospital. The
27
410 FIBRO-CELLULAR TUMORS.
tumor had attained the weight of twenty-four pounds; the testicle, with
a distended tunica vaginalis, lay pressed down below it, and the hernial
sac was quite clear of it above. It was easily separable from the sur-
rounding tissues, into which many lobes extended far from the chief
mass, and on section appeared partitioned into lobes of various sizes
and shapes. It had all the characters which I have described as be-
longing generally to these tumors, varied only by the unequal collec-
tions of blood or of serum, or by its various firmness of texture in its
several portions.
A similar case was brought to St. Bartholomew's by Mr. G. B.
Thompson, to whom I am indebted for the history. The patient was a
parish clerk, 70 years old, a sickly-looking man, and the tumor had
been nine years in progress before his death. It was first noticed as a
hardness just above the testicle; but as it constantly increased in size,
it filled the whole scrotum, displacing the adjacent integuments, and
looking at first sight like an enormous hydrocele. Its surface was
uneven and lobed, in some parts feeling hard and brawny, in some soft
and fluctuating. For many years it was inconvenient only by its size
and weight; but, about a month before death, one of its prominent parts
sloughed, and hemorrhage took place from it. After this, more exten-
sive sloughing took place, and more considerable hemorrhage, and the
patient sank.
The tumor had the same characters as the last, except in the part
that was sloughing, which was denser and more compact, and of a dark
blood-stained color, like congested liver. This might have been thought
cancerous; but with the microscope I found only fibro-cellular tissue
infiltrated with inflammatory exudation and blood; in other portions,
unmixed fibro-ccllular tissue.*
To these cases I might add one related by M. Lesauvages,f in which
the tumor, in a man 70 years old, weighed at least 44 pounds, and was
of such size that, as the patient sat with it resting on his thighs, it
reached to his sternum and beyond his knees. And another of the
same kind is related by Dr. O'Ferrall, which he removed successfully;
but, excellent as the surgery of this case was, its pathological complete-
ness is marred by the suspicion that a small portion of it was of can-
cerous structure, and by the finding of a " solitary, hard, circumscribed
tuber'* in the patient's liver, when, some months after complete reco-
very from the operation, he died with phthisis.J
* The two foregoing cases are published by Mr. Thompson in the Medical Gazette, Miy
30, 1851.
f Archives G^n. de M^d^ t. ix, p. 212, 1845. M. Lesauvages refers to another Terjr
probable case in which Bayle removed the tumor. It was of three or four years' growth,
and as large as a head. The patient died, without return of the disease, seven or eigbt
years afterwards.
f I am indebted for these particulars, beyond what were published in the Dublin Jourml
of Medical and Chemical Science, vol. i, 1846, to the kindness of Dr. OFerrall. Mr. Ci«^
ling (On Diseases of the Testis, p. 51) refers to two cases of small " fibrous" tumors remored
FIBRO-CELLULAR TUMORS. 411
Of the similar tumors growing by the vagina, the best instance that
I know is that recorded by Mr. Lawrence.* A portion of the tumor
is in the Museum of St. Bartholomew's Hospital ; and, though altered
from its first condition, it proves the identity of the disease with that
of which I have been speaking.
The patient was a lady, twenty-eight years old, and the tumor, sus-
pended from the labium and buttock as far as the coccyx, reached near
to her knees, was as broad as her two thighs, and measured 32 inches
in its greatest circumference. It had been growing four years, and
produced no inconvenience except by its weight and bulk. It was soft
and lobed, and the skin was loosely connected with it. Mr. Lawrence
removed the greater part of this tumor ; but a portion which advanced
into the labium and along the side of the vagina could not be eradicated :
this was therefore cut across ; and, when it had grown again, was re-
moved in a second operation two years afterwards. The patient then
recovered perfectly, and is still living, without any return of the dis-
ease, more than twenty years after the operation. Mr. Lawrence's
account of the tumor, and its present appearance, leave no doubt that
it was of this fibro-cellular kind.
A similar specimen, weighing more than 10 pounds, was removed by
Mr. Liston from a patient thirty years old, in whom it had been grow-
ing many years, and a portion of it is in the Museum of the College
(No. 2715). Many of smaller size have been removed from the same
part ;t and I have met with two which have presented the same disease
in another phase.
A woman, thirty-four years old, had a tumor pendulous from the
right wall of the vagina and the right nympha. It was a large flask-
shaped mass, about five inches in diameter, attached by a pedicle about
one inch and a half in length and thickness, over the upper part of
which the orifice of the urethra was arched. All the lower part of the
tumor was sloughing, and discharging an offensive ichorous fluid. The
upper half was covered with healthy mucous membrane, and felt uni-
formly tough, pliant, and elastic.
The patient had noticed this disease for three or four years. It
began as a tumor, projecting into the vagina from beneath its right
from the scrotum, in one of which the tumor was supposed to be a third testicle. These
were probably of the kind here described. So, probably, were those referred to by Schub
(Pseudoplasmen, p. 69), in one of which a fatty tumor was combined with one of several
"fibroid" tumors in a scrotum. Other cases in the scrotum are also described by Mr. Hut-
chinson in the Med. Times and Gazette, December 31, 1853. And in the Lancet, July,
1856, is recorded a case in the practice of Mr. Fergusson where the tumor recurred in the
scrotum.
* Medico-Chirurgical Transactions, vol. xvii, p. 11.
f Mr. Lawrence, 1. c, refers to one by Mr. Earle. Cases are also described by Sir B. C.
Brodie, Med. Craz., vol. i, p. 484 ; Mr. Cffisar Hawkins, Med. Graz., vol. zxi, p. 925 ; Mr.
Carling, Proceedings of the Pathological Society, Part ii, p. 301 ; and (probably) by Dr.
Cf Fernill, Dublin Journal, vol. i, p. 520, and vol. iv, p. 337. A specimen from a case by
Mr. Keate it in the Museum of St. George's Hospital.
412 FIBRO-CELLULAR TUMORS.
wall, and in this situation acquired a large size before it protruded ex-
ternally. It was punctui:ed, and then grew more rapidly ; but the pro-
trusion did not take place till about ten days before I saw the patient
After this protrusion it enlarged very quickly, and, with the sloughing,
the general health suffered severely. I removed the tumor eighteen
months ago, dissecting it out with little difficulty, and the patient, I
believe, remains well.
It presented a well-marked instance of a very oedematous and slough-
ing fibro-cellular tumor, and microscopic examination found abundant
inflammatory exudation mingled with the rudimental fibro-cellular tissue.
At nearly the same time I saw a case essentially similar to this ; but
the tumor was suspended from the labium, and the patient was about
sixty years old. And this last fact is, perhaps, worth notice; inasmuch
as, with this exception, all the cases of the fibro-cellular tumor by the
vagina that I have met with have occurred in young women, while all
the similar tumors in the scrotum have been in old men.
The occurrence of such tumors as these in the scrotum and labium
may make it necessary that I should particularly say they are not the
same disease as are the cutaneous growths which form the pendulous
tumors — the elephantiasis, as it is sometimes called — of the same parts,
and which I have already briefly described. The main differences are:
1st. That these fibro-cellular tumors may be separated or enucleated
from the tissues among which they lie ; whereas the cutaneous growths
have no definite boundary, but are continuous with the proper tissue of
the scrotum, or labium, or nympha : the two diseases have the common
differences between tumors and outgrowths. 2d. In the growth of the
fibro-cellular tumors, the surrounding parts, including the skin, or the
mucous membrane, grow in adaptation to the tumor, but often defec-
tively, or, at the most, only normally ; but in the cutaneous outgrowths
all the tissues take part, and the proper tissue and appended organs
of the cutis are nearly as much exaggerated as the fibro-cellular sub-
stance. And 3dly. In the tumors, fibro-cellular tissue is the highest
form attained, or, at most, a small quantity of elastic tissue is mingled
with it ; but, in the outgrowths, all the component structures of the
skin and subcutaneous tissue are increased.
The two diseases are thus different. Still, the fact is significant that
the parts most liable to the cutaneous outgrowths are also those in or
near which the fibro-cellular tumors most frequently occur ; and it maj
be noted that, among those parts in which fatty tumors are most rare,
the fibro-cellular are the most common.
For examples of fibro-cellular tumors removed from deep intermus-
cular spaces, I may refer to two specimens already described, and to
two others in the Museum of St. Bartholomew's Hospital. One of
these was removed twelve years ago, by Mr. Stanley, from an elderly
man : it lay under the vastus internus muscle, and was easily dislodged
i
FIBRO-CELLULAR TUMORS. 418
from the cavity in which it was imbedded: it was a smooth, spheroidal
mass, thinly incapsnied, and the bright yellowish color of its surface
made it to be regarded as a firm-textured fatty tumor ; but the micro-
scope found little or no fat in it, and its present aspect leaves no doubt
of its nature. The patient died after the operation, and had no similar
disease in other parts.
The second of these specimens was removed, by Mr. Savory, from
beneath the tensor vaginse femoris of a man 38 years old. It was of
uncertain date, but had been observed about five months : it was firm,
elastic, smooth, movable, and painless. In the operation it was easily
removed from its resting-place on the rectus muscle and the inferior
spine of the ilium ; the patient recovered perfectly, and has remained
well for nearly two years.
This tumor was a smooth oval mass, measuring about 5 inches by 8^.
Both in general aspect and in microscopic characters it might have
been taken for a type of the species, except for the peculiarity of its
being at one end capped with a layer of cartilage and cancellous bone,
and having nodules of cartilage set along the course of one of the chief
partitions between its lobes (Fig. 58).
To these specimens I maj add another, in the College Museum, of
which Mr. Hunter has left the record that it w^as taken from the thigh,
and had been supposed to be an aneurism.'*'
These seem to be the most common seats of the fibro-cellular tumors,
but I have preserved specimens from other parts. One was removed
by Mr. Stanley from the sole of the foot, where, surely, we might have
expected a fatty rather than any other tumor. The patient was a
healthy man, 41 years old, and the deeply bilobed and very prominent
tumor lay in the subcutaneous tissue over the metatarsal bones, with
small lobular prolongations extending among the deeper-seated tissues.
It was of eight years* growth, and nodules of cartilage were imbeddecj in
the pliant and oedematous fibro-cellular tissue of many of its lobules.
Another of these specimens was removed by Mr. John Lawrence,
with the testicle, within the tunica albuginea of which it appears to be
entirely inclosed. The patient was a healthy-looking man, 87 years
old, and the tumor had, in seven years, grown to a measurement of
nearly six inches by four. When first removed, it was to the eye
exactly like a fatty tumor, but it contained no fat, and was a typical
specimen of fibro-cellular tumor in a very oedematous or annsarcous
state.
A third was removed from over the upper part of a girl's saphena
vein, by Mr. Skey. It was completely incased in bone ; but its mass
was perfect soft and elastic fibro-cellular tissue.
* Two retanarkably good cases have been recorded by Sautesson in Hygeia (translated in
Ooblio Jonmal, toI. xz). They lay just external to the peritoneum, between it and the
rectus and transvenalis muscles, and both were examples of very rapid growths.
414 FIBRO-CELLULAR TUMORS.
A fourth specimen is a tumor which I removed from the orbit of a
man 40 years old, in whom it had been growing for about eighteen
months. It has the general and microscopic characters of the species,
but is very soft, and is composed of a cluster of small masses, looking
almost like a bunch of small gelatinous polypi of the nose.*
A fifth is an oval bilobed tumor, about half an inch in diameter,
which I removed from a young man's tongue, in the very substance of
which, near its apex, it had been growing for three years. It was
firmer than most of the others, yet succulent, and formed of an ob-
scurely filamentous tissue, abundantly nucleated.
The specimens to which I have now referred will be sufficient, I
think, to justify the giving a distinct name to the kind of tumor of
which they are examples. There may be found, indeed, many speci-
mens that will connect these with fibrous tumors ; but, as I have already
said, if we may, among the natural tissues, distinguish the fibro-cellalar,
areolar, or looser, from the fibrous, tendinous, or denser form of con-
nective tissue, so should we make a corresponding distinction of the
tumors that are respectively like them.
I need only add a few words respecting the general history of these
tumors. They have been found, I believe, only in or after the adult
period of life, and in persons with apparently good general health.
Their causes are wholly unknown. ^ Their development appears to be
like that of the natural fibro- cellular tissue, and I have often found in
them abundant cells lengthening and attenuating themselves as in die
organizing of lymph or granulations. These I am disposed to regard
as proper rudimental parts of the growth ; for they are often peculiarly-
well marked, and have no appearance of being produced in disease.
The growth of these tumors is quick, in comparison with the average
rate (so far as we can roughly estimate it) of innocent tumors. Tbey
often enlarge very quickly ; but this enlargement is probably not growti,
but swelling, through increase of the oedematous effusion (and this dif-
ference between growth and swelling may be usefully remembered in
the diagnosis of many tumors). The growth is usually painless, Wj
about the vagina is apt to be too rapid for the superjacent tissues, hi
possible extent is very great. I have mentioned one tumor of 44poafli^'.^£,
weight, and another of 24 pounds, which was still growing.
Of the diseases of these tumors nothing has been yet observed, exert
the sloughing and suppuration that occurred in one of the cases I
mentioned. As to their nature, all that has been said implies
•
* Three cases of tumor in the orbit, which, I tliink, innal have been likelhis,!*^
scribed by Schuh (p. r>3) under the names " Zellgewebsschwamm,*' " Fungus cell
Besides the specimens above described, which are all in the Museum of St. Bai
I have seen two removed from the scalp, botli of which, before removal, were Mipp
be cutaneous cysts. A tumor removed by Dr. Humphry (Lectures on Surgery, p. IST)1
a finger, and one described by Lebert (Phys. Pathol., t. ii, p. 173) as a fibrous tumor <
neck, were probably of this kind.
FIBBO-OELLULAR TUMORS. 415
they are completely innocent ; and I have seen no sufficient reason to
doubt that they generally, or always, are so. Once, indeed, I think
such a tumor recurred after removal ; and once, in the testicle, a small
growth of medullary cancer existed near, but separate from a large
fibro-cellular tumor: but these are the only suspicious cases I have
known.*
* Of late years lome attention has been directed in Germany to a form of tuaior charac-
terized by porsessing as its peculiar elements perfectly hyaline, structureless, bladder-like
and cylindrical bodies, from many of which cactus-like sprouts or vegetations arise. The
priority of discovery would appear to rest with H. Y. Meckel, though the first published
cases in which the peculiarities of the tumor were indicated are by W. Busch (Chir. Beo-
bacht. Berlin, 1854), and by Y. Graefe (Archiv, B. i, p. 416). Billroth was, however, the
first to give any detailed account (Untersuch. Qber die Entw. der Blutgeftsse, Berlin, 1856)
of the structnres contained in this form of tumor, and owing to the numerous cylindrical
hyaline structures in it, he proposed the name of Cylindroma, cylinder-tumor. The case
which he examined was that which had previously been described by Bu&ch. H. Y. Meckel,
from a supposed affinity between the cylindrical bodies and cartilage, gave the tumor the
name of Schlauch-Knorpel-Geschwulst — cylindrical cartilaginous tumor (Charit^ Annalen,
Tii, Jahrgang, S. 96). Another case has since been described by Yolkmann (Yircbow's
ArchiT, B. xii, p. 293, 1857), and Forster has described and illustrated a fif\h and a sixth case
in his Atlas of pathological microscopic anatomy. 1859. Taf xxx, p. 47.
The tumor in the case described by Busch and Billroth, occurred in a man, cet twenty-
two, strong and healthy, and of a healthy family. It appeared in the fossa lachrymalis of
the right orbit, and about three years afterwards was removed by an operation. In about
five months it reappeared and was again removed. Both these tumors were examined by
Busch ; the first was looked upon simply as a hypertrophy of the lachrymal gland, but in the
leoond the peculiar cylindrical structures were observed. The tumor recurred and was re-
moved five times after the second operation, and at length the patient died about six years
after its first appearance. No post-mortem examination was made. The five last tumors
were examined by Billroth, and it is from them that he draws up his account of the structure.
• They were composed of larger and smaller lobules, tolerably elastic in consistence, each lobule
being invested by a capsule of connective tissue. The tumors on section bad a distinctly
meahlike structure, some of the meshes being as large as a pea, others very much smaller.
This arrangement was produced by a network of connective tissue in which bloodvessels
were imbedded. The contents of the meshes were of a clear yellowish-red color, readily
hnaking down, and sometimes even of a pap-like consistence.
" When examined microscopically a branched and ramifying system of glassy-clear, ex-
> tremely transparent, pale cylinders, was seen, which frequently anastomosed, presented many
^ Ttrioosities, and often swelled out into rounded knob-like masses at their extremities. These
[^ Billroth called the hyaline cylinders. At other times clear, glassy, isolated globular or blad-
^^ ^-like structures were visible. Yolkmann described in his case the hyaline cylinders as
^.^ not onfrequently radiating from a common globular centre, and giving ofi* branches in a
^^ MctQi-like manner. He and Forster consider that the cylinder and globules have a deflnite
nombrane around them, but Billroth doubts if any such membranous investment exists.
i^Wiiilst numbers of these bodies possessed no differentiation of structure in their interior, and
ding to Yolkmann were often hollow and with fluid contents, some had extending
their axes branched, star-like or spindle-shaped cells, with pale but distinct nuclei,
'^^B had a fine string of delicate connective tissue running down the interior, whilst others
were packed full of roundish granular cells, and these last Billroth termed cell-cylin-
These cell-cylinders had very much the appearance of the follicles and tubes of
a, and were at first mistaken for them. The hyaline cylinders and cell-cylinders in-
ed with each other, and formed together a trabecular arrangement, in the meshes be-
» which trabeculee crowds of small, round, oval, or polygonal cells were imbedded.
h described in some of the hyaline cylinders the development of bloodvessels by the
nee of spindle-like cells, an observation which has been confirmed by Forster.
416 PAINFUL SUBCUTANEOUS TUMORS.
Painful Subcutaneous Tumors.
A group of tumors, peculiar for the pain with which they are con-
nected, is thus named, and is so remarkable as to justify giving a de-
scription of them separate from that of the fibro-cellular and fibrous
tumors, with which, considering their other characters, the chief exam-
ples of them might be placed.
The painful subcutaneous tumor, or tubercle, has been often well
described in relation to its general characters. Its intense painfulness
was too striking to escape observation. It was described by A. Petit,
Cheselden, Camper, and others ; but the first, and to this time the beet,
general account of the disease, drawn from many instances, was given
by Mr. William Wood, in 1812.* Dupuytren added many instances
to those which he copied from Mr. Wood's paper, and made the disease
much more widely known.f
The especial seat of growth of these little tumors is, as their name
implies, in the subcutaneous areolar and adipose tissue. They are most
frequent in the extremities, especially the lower : very rarely they occur
on the trunk, or the face.J They are about four times more frequent
in women than in men ; they rarely, if ever, begin to form before adult
life, or after the commencement of old age. It is seldom that local
The characteristic cylindrical and globular structures are now nnostly regarded as belong-
ing to tliut softer, modified, and nnore rudimental form of connective tissue which has been
recently named mucous tissue. Volkmann considers that the globules are formed by the eo-
largement of pre-existing tissue-cells into transparent ball-like masses, and that from thefe,
as from a mother-cell, the hyaline cylinders branch out by a system of lateral sprouting. In
these cylinders and globules a process of cell-formation may goon from the old cell-nucleus,
by endogenous cell-multiplication, until they become packed with small cells.
Although the structures now described were at first thought to be characteristic of a dis-
tinct form of tumor, yet the later observations hardly appear to bear out the original supposi-
tion. The cases on which Volkmann and Forster founded their descriptions were rapidly
spreading cancroid ulcers with which the characteristic hyaline cylinders and globules were
incorporated, from which circumstance the latter describes the tumors by the name of muconi
cancroids (Schleim-Cancroids). Billroth himself, in a later communication "On Tumors of
the Salivary Glands' (Vijchow's Archiv, 1859), states that he has not unfrequently found,
in tumors of the parotid, structures corresponding to those described by him in Cylindromi.
He is now, therefore, with Forster, disposed to regard the cylinders and globules as growths
of mucous tissue, which may combine with the textures of other forms of tumors.
It is in accordance with the view that these structures are closely allied to the more rudi-
mental forms of connective tissue, that this account of them has been inserted as an appendix
to the description of the fibro-cellular tumors. Any classification, however, at present
adopted, must be regarded as merely provisional, the number of cases up to this time re-
corded, in which these structures have been met with, being loo few, and the conditions
which determine their formation being too little understooil, to permit one to come to a finil
conclusion. It may have happened that, in some of the examples of the fibro-cellnlar
tumors described in the text, the peculiar cylindrical structures may have existed, though,
through imperfect examination, they were not recognized.
* Edinburgh Med. and »Surg. Journal, viii, 1812. Mr. Wood first gave these tumors the
appropriate name which they have since borne.
f LcQons Orales, i, 530. He named them fibro-cellular encysted tumors.
J One is mentioned by Mr. Ciesar Hawkins, as removed from the cheek by Sir B. C.
Brotlie (Medical Gazette, vol. xxi, p. 926) ; and one by Dupuytren.
PAINFUL SUBCUTANEOUS TUMORS. 417
injary, or any other cause, can be assigned for their occurrence. The
tumor usually lies just beneath the skin, scarcely prominent ; it has a
capsule loosely connected with all the surrounding parts, unless it be
to the cutis, to which it may be tightly fixed, and which, in such cases,
18 generally thin, tense, polished, and like a superficial scar. Some-
times the small bloodvessels of the skin over and around the tumor are
enlarged and tortuous, like those near a cutaneous nsevus ; but, else, all
the adjacent parts appear healthy.
Tumors of this kind rarely exceed half an inch in diameter ; they are
usually spheroidal, oval, or cylindriform ; they are firm, nearly hard,
tense, and very elastic. Their outer surface is usually smooth, bright,
yellowish, or grayish, or pure white ; and their sections have the same
aspect and consistence, or are varied by an obscure appearance of pure
white fibres traversing a grayish basis.'*'
Among the painful subcutaneous tumors that I have been able to ex-
amine microscopically, one was composed of dense fibrous tissue, with
filaments laid inseparably close in their fasciculi, and compactly inter-
woven. # These appeared to have been formed in or from a nucleated
blastema ; for thickset, oval, and elongated nuclei were displayed when
acetic acid was added. Another was composed of well-formed fibro-
oellalar tissue, with bundles of parallel undulating filaments, matted or
closely interwoven. With these were elongated fibro-cells, the pro-
duets, perhaps, of infiammation, to which the tumor appeared to have
been subject. The substance between the filaments, and that from
which they were probably developed, was here, also, a nucleated blas-
tema. A third specimen presented obscure appearances of a filamen-
tous structure, but no separable filaments : it seemed composed wholly
of such nucleated blastema as was exposed by the action of acetic acid
on the former specimens. In some parts, also, this presented appear-
ances of filaments and nuclei arranged in concentric circles around
small cavities.f A fourth, which had existed for many years at the
end of a woman's thumb, consisted of large clear nuclei in a dimly-
shaded homogeneous substance. One, from the front of the abdomen,
was like a common fatty tumor.
From these examples, or, at least, from the first three, we may be-
lieve that the painful subcutaneous tumors may be formed of either the
looser fibro-cellular or more dense fibrous form of connective tissue, in
either a rudimental or a perfect state. They may also, I believe, be
fibro-cartilaginous, as described by Professor Miller,J and by many
* Sometimes the tumor has a central cavity filled with fluid, as in two cases by Mr. Car-
mthers, in Edin. Med. and Surg. Jour., vol. xxxiii; but it is observable that in one of these,
occurring in a man, a visible nerve was connected with the tumor. Perhaps this was a
Dcnroma ; for in these the cystic character is not unfrequent
f Like those drawn from a fibrous tumor of the uterus by Prof. Bennett (On Cancerous
and Cancroid Growths, p. 189).
J Principles of Surgery, p. 602, 3d Ed. An engraving, from the sketch by Prof. Ben-
nett, makes this the only sure instance of fibro-cartilaginous structure. In the other recorded
418 PAINFUL SUBCUTANEOUS TUMORS.
Other writers. But whatever such slight diversity of tissue they may
present, the characteristic of all these tumors is their pain; pain which
may precede all notice of the tumor, or may not commence till much
later, or may be contemporary with it, but which, when once it has set
in, may rise to very agony, such as I suppose is not equalled by any
other morbid growth. It is not often constant ; but, generally, without
evident cause, or with only a slight touch of the tumor, a paroxysm of
pain begins, and, gradually increasing, soon reaches a terrible severity.
Beginning at or near the tumor, it gradually extends into all the adja-
cent parts, often flashing, like electric shocks, from one part of the limb
to another, or to the whole trunk. Such a paroxysm may continue for
a few minutes, or for several hours ; then it gradually subsides, leaving
the parts sore and tender. While it lasts, the tumor, whatever may be
its condition at other times, is always exquisitely sensitive : the mus-
cles of the limb may act with irregular spasms ; or general convulsions,
like those of an epileptic seizure, may ensue ; or, the patient falls as if
sunk by the intolerable pain, and faints. Sometimes too, the tumor
itself swells, the bloodvessels around it become larger and m^re tor-
tuous, and the skin becomes cedematous or congested, imitating the
change which sometimes ensues in a neuralgic part. There are many
diversities in the characters and modes of the pain ; but this belongs to
all the instances of it, — that its intensity is altogether disproportionate
to its apparent cause, and that it cannot be explained by anything that
can be seen in the structure or relations of the tumor.
This pain suggests interesting questions in relation to the pathology
of tumors ; but, before considering it, let me add some facts to complete
the history of these. They appear usually to be of very slow growth.
One, which I removed from the end of a thumb, had existed fourteen
years, and was less than a quarter of an inch in diameter. Another,
which I removed from the leg of an elderly woman, had gradually in-
creased for ten years ; yet, at last, it was less than half an inch in
diameter. In other cases they may more quickly attain the same size;
but this seems their limit ; and, for any number of years, they may re-
main sources of intense pain, and yet undergo no apparent change of
size or structure.- They are usually single. I have found only one
case in which more than one existed : in this case three lay close to-
gether over the great gluteal muscle.* When excised, they are not apt
to recur. I removed one from the back of the leg of a lady 28 years
old, from whom, two years previously, a similar growth was excised
from the same part. After the first operation the pain was scarcely
changed ; after the second it ceased, and never returned. Sir Astley
Cooperf removed two painful tumors, at an interval of a year, from a
young lady's leg ; but these are the only instances of apparent recur-
cases the microscope was not used ; and the naked eye cannot discern between fibrous car-
tilage and dense fibrous tissue.
* W. Wood, 1. c. j* lUustr. of Diseases of the Breast, p. 84.
PAINFUL SUBCUTANEOUS TUMORS. 419
rence that I have found. I believe that they have no tendency to
ulcerate, or to assume any of the peculiar characters of malignant dis-
ease.*
In considering, now, the painfulness of these tumors, the first ques-
tion is their relation to nerves : are nerves involved in them ? and do
they, as Velpeauf seems to hold, differ from neuromata, i. e. from the
fibrous or fibro-cellular tumors within the sheaths of the nerves, only in
their position ? are they only tumors within the superficial or subcuta'^
neous nerves ?
The general opinion is against this supposition. Dupuytren says
that he dissected several of these tumors with minute care, and never
saw even the smallest nervous filaments adhering to their surface. I
have sought them with as little success with the microscope. Of course,
I may have overlooked nerve-fibres that really existed. It is very hard
to prove a negative in such cases ; and cases of genuine neuroma, t. e.
of a fibrous tumor within the sheath of a nerve, do sometimes occur
which exactly imitate the cases of painful subcutaneous tumor. Such
a case was under Mr. Stanley's care some years ago. An elderly gen-
tleman had for two years observed a small subcutaneous tumor over the
lower part of the semi-membranosus muscle. It was easily movable,
and, till within the last three months, had not been inconvenient ; but
at this time it became the seat and source of pain exactly like that of a
painful subcutaneous tumor. It was removed ; and I was able to trace,
with the microscope, an exceedingly slender nerve, the filaments of
which were spread out over one part of the tumor. The tumor was
within the neurilemma, and was uniformly firm, elastic, yellowish, and
composed of well-formed fibrous tissue.
Many that have been called painful subcutaneous tumors may have
been such neuromata as this was. Still, I am disposed to think that most
of them are only so connected with nerves as ordinary innocent tumors
are, that receive a few nerve-fibres in their substance. For (1) the con-
nection of the nerves with even very small neuromata is not so difficult
to demonstrate, but that it should have been found, if it had existed, in
some of the many painful tumors that have been examined. (2) The
neuromata often occur in large numbers in the same patient ; the pain-
ful subcutaneous tumor is nearly always single. (3) The neuromata
usually grow constantly, and seem to have no limit of size ; even when
subcutaneous, they commonly exceed the size of the painful tumors,
which generally grow to a certain small size, and in it remain station-
ary. (4) Neuromata are most frequent in the male, the painful subcu-
* Dr. Warren (On Tumors, p. 60) speaks of a malignant form of the disease in which
the lymphatics are aifected,but relates no case of it. The case requiring amputation which
he relates appears to have owed its severity to the treatment. Dupuytren (Le9ons Orales,
i, 542) says they have or may acquire a scirrhous nature, and then end with cancerous soft-
ening ; bnt be refers to only one case justifying such expressions, and this case is imperfectly
described.
f M6decine Op^ratoire, torn, iii, p. 101.
420 PAINFUL SUBCUTANEOUS TUMORS.
taneous tumors in the female sex. An analysis of 26 cases of neuroma
taken promiscuously showed that 19 had occurred in men, and 7 in
women ; while in 28 cases of painful subcutaneous tumors 23 were in
women, and 6 in men ; evidence which is almost conclusive for the diflFer-
ent natures of the two diseases.
However, even if it could be proved that these painful tumors are
within nerves, the question respecting the source of pain would not be
fully answered. We cannot ascribe the pain to merely the altered me-
chanical condition of the nerve-fibres ; for tumors that are evidently
within nerves are not always, nor even usually, painful. It is remark-
able that, in nearly all the cases in which large tumors have existed in the
trunks of nerves, there has been little or no pain. The facts collected
by Dr. Smith* are clear on this point. Moreover, the subcutaneous
tumors themselves often remain long painless, and then become, without
any other apparent change, extremely painful ; and there are instances
of tumors exactly resembling them, except in that pain has never been
felt in them. I removed such a one from a lady's forehead. It was
about as large as a pea, had been two years growing in the subcuta-
neous tissue, and had never given pain except once, when it was severely
struck. It had all the apparent characters of structure of the painful
subcutaneous tumor. I repeat, therefore, that we cannot assign the
pain in these cases entirely to an altered mechanical condition of the
nerve-fibres in or near the tumor. We must admit, though it be a vague
expression, that the pain is of the nature of that morbid state of nerve-
force which we call neuralgic.
Of the exact nature of this neuralgic state, indeed, we know nothing;
but of its existence as a morbid state of nerve-force, or nervous action,
we are aware in many cases, in which we can as yet trace no organic
change, and in many more, in which the sensible organic change of the
nerves is inadequate to the explanation of the pain felt through them.
In both these sets of cases we assign the pain (speaking vaguely) to a
functional, rather than to an organic, disorder of the nerves ; to a dis-
order commencing in the nerves of the part which is the focus of the
pain, but transmitted from them to others which, in the nervous centres,
are connected with them.
With this view of the neuralgic nature of the pain in the subcutaneous
tumors many of their characters and circumstances agree. The pain
is commonly paroxysmal, and sometimes regularly periodical ; it is
difiuse, or flashing, electric, and most intense; it often excites reflex
spasmodic movements, or more severe and general convulsions ; though
not peculiarly frequent in persons of extreme sensibility, yet it is often
aggravated by mental emotions, and the other excitants of neuralgic
pains ; it is sometimes increased, or first felt, about the time of the
cessation of the menstrual discharge ; it sometimes remains at or about
the seat of the disease for a long time after the removal of the tumor ; it
* Treatise on Neuroma.
PAINFUL SUBCUTANEOUS TUMORS. 421
is sometimes attended with what is regarded as reflex vascular fulness,
but it precedes no organic change.
The consideration of the probably neuralgic nature of the pain in
and about these tumors is of interest in relation to the pathology of
many others. The pains of many other tumors are probably, in greater
or less measure, of the same nature.
The irritable tumor of the breast may be called a neuralgic tumor.
Sir Astley Cooper's plates show, indeed, that some which he thus called
were like the painful subcutaneous tumors ; but the more frequent are,
I believe, mammary glandular tumors, imitating in their structure the
mammary gland itself, or small portions of indurated gland. I derive
this belief from the general appearance and description of several spe-
cimens, and from what I found in two cases with the microscope. A
woman, 45 years old, was under my care with a small tumor lying deep
in her breast, which felt hard and not movable, except with the tissue
around it. She had been aware of this tumor for a month, and during
all the time it had been the source of intense '^ darting and dragging''
pain, which often extended from it through the chest to the shoulders,
and along the neck and arms. The pain was described as so like that
commonly assigned to cancer of the breast, that, judging from it, and
from the age and other circumstances of the patient, one could not but
fear she had cancer. The doubt rendered it proper to make an explo-
ratory incision at the commencement of the operation. This was done,
and the tumor having no cancerous aspect, was alone removed. It
proved to be a perfect example of mammary glandular tumor, such as I
shall more fully describe in a future lecture. Thus the case seemed to
be one of mere neuralgia in a glandular tumor of the breast : and it
may be added, that it was only a striking instance of an ordinary fact ;
for such tumors are often at times extremely painful.
Similar instances might be found, I believe, in tumors of other struc-
tures ; but, without entering further on their history, I would suggest
that the account of all these painful tumors makes it probable that the
pain the patients feel is, in great measure, neuralgic or subjective ; that
it has the tumor indeed, for an exciting cause ; but that it owns, besides,
some morbid condition inherent or cumulative in the nerves themselves,
80 that at times they respond, with a morbid exaggeration, to an habi-
tual or slightly increased stimulus. And if this be true of the most
painfal tumors, it is probably true, in various measures, of many others.
422 FIBROUS TUMORS.
LECTURE XXV.
FIBROUS TUMORS.
The name of " fibrous tumor" appears the best, among the sixteen or
more, by which different writers have described the tumors whose chief
characteristic is their likeness to the natural fibrous, tendinous, or
aenser form of connective tissue of the body. This, at least, seems the
best for a general designation ; and to those among them which are con-
structed of more than one elementary tissue we may give such names
as "fibro-muscular," "fibro-elastic,'* ** fibro-cartilaginous," &c.
The most frequent and notorious examples of the species are the
fibrous tumors, or fibrous bodies, of the uterus ; the " hard, fleshy tu-
bercle of the uterus,'* as it was described by Dr. Baillie. From these,
chiefly, the general, though not all the microscopic, characters of the
species may be described.
First, however, the usual distinction must be drawn between the tu-
mors and the outgrowths of the same structure. The uterus presents
examples of both.
The Fibrous Polypi of the uterus, more properly so called, are
continuous outgrowths of and from the substance of the uterus ; the
mucous membrane and the muscular and fibrous tissues of the uterus,
growing, in variety of proportions, into its cavity and that of the vagina.
The fibrous tumors are discontinuous growths of similar tissue in or near,
not of, the substance of the uterus.*
The distinction is often difficult to make during life ; for the pendu-
lous, polypoid, and narrow-stemmed outgrowth may be imitated, in all
its external characters, by a tumor growing near the surface of the
uterus, and projecting into its cavity, with a gradual thinning invest-
ment of its muscular and mucous tissues. On dissection, however, or
in such a section as the adjoining diagram (Fig. 54) may represent,
the continuity of the polypus or outgrowth, A, and the discontinuity of
the more commonly occurring tumor, B, may generally be discerned,
even in specimens which, like two in the Museum of St. Bartholomew's
Hospital, are, in external appearance, exactly alike (xxxii, 12 and 34).
Similar differences exist among what are classed together as fibrous
tumors of bone or periosteum : some, as we shall see, are tumors ; some
are outgrowths, and the line of distinction cannot be well drawn.
Fibrous outgrowths are also, sometimes, found in the form of polypi
suspended in the pharynx, or in the chambers of the nose, or in some
* The distinction is expressed by M. Cruveilhier (Anatomie Palhologique) by the terms
"corps fibreux implantes," and "corps fibreux non implant^s*/' but the "corps fibreux" of
the breast, which were described by him, and led to the renowned discussion at tlie French
Academy of Medicine, were, for the most part, mammary glandular tumors, and nearly solidi*
fied proliferous cysts.
yiBHODB TDIIOBS.
Fig. 6t»
of the oavities connnnnicating with them. Bat I have not been able to
examine uij of these minutely in the recent state; and I have seen
so few in snj condition, that I cannot tell
whether some, or even many, of them are not
separate fibrous tumors, projecting the mucous
membrane, and pendulous, as fatty tumors
often are, when they grow just beneath the
cutis. Neither the description by Schuh, ac-
curate aa it is in other points, nor any other
that I remember, decides this. The same un-
certainty exists as to the relations of the ex-
tremely rare fibrous polypi of the oesopha-
gus and larynx. The fibrous structure of nil
these growths is well marked, but compara-
tively soft and elastic, and intermediate be-
tween the structures proper to the typical
examples of the fihro-ccllular and the fibrous
The Fibrous Tuhorb, of which alone I shall
now speak, appear to have a natural tendency
towards a spherical or oval shape, with a smooth
or superficially lobed surface ; but from these
marks they often deviate, in adaptation to
mutual pressure or the different resistances of
surrounding parts. When, for example, a
fibrous tumor is pendulous, its more dependent portion usually grows
most, or is most swollen ; it tends from the spheroidal to the pyriform
shape, but retains a smooth surface: when one grows into a cavity, it
is apt to assume the shape of that cavity, whatever it may be, or else to
become deeply lobed. Such varieties as these are often seen in the
fibrous tumors of the upper jaw, according as they grow into the cavity
of the mouth, or in other directions ; and greater diversities occur among
many specimens of the fibrous tumors of the uterus.
The fibrous tumors growing in solid organs have usually a complete
connective tissue capsule ; and in the uterine walls this is peculiarly
dry and loose, so that, when one cuts on the tumor, it almost of itself
escapes from its cavity. So, too, are covered the fibrous tumors in the
Bubcataneous tissue and in the nerves, and those parts of the fibrous
tumors and outgrowths from bones which are in contact with other
tissues than those from which they spring.
To the touch the fibrous tumors are usually very firm, often extremely
* Fig. &4, diagrain-aeuiloiu of t
■ra like potn>ii but the former is
aitconUDiMUi. See owi by Db'
lilt 18SS, p. 142.
oulgiowth (a) and of b uleriap lumor (■). Bolh
iili Iho subsmnce of ibe ulerus; the lallet is
ind Laboulliens in ilie C. R. de Ih Soc. de Binlogie
424 FIBROUS TUMORS.
SO ; they may even be as hard and incompressible as hard cancers. If
they are soft, or "fleshy," or succulent, it is, I think, always through
oedema or inflammatory softness and infiltration of their substance ; for
such characters as these are rare, except in the case of the pendulous
or protruding tumors, or in those that are manifestly diseased. More-
over, in all ordinary cases, the fibrous tumors are heavy, very elastic,
and very tense, so that their cut surfaces rise in convexities, like those
of intervertebral fibrous cartilages.
In the examination of sections, of which Fig. 57 may represent an
ordinary example, the most usual characters that one sees are, that the
tumors present a grayish ba»is-substance, nearly homogeneous, and in-
tersected with opaque, pure wliite bands and lines. They have a general
resemblance in their aspect to a section of fibro-cartilage, such as that
of the semilunar or the intervertebral cartilages. Many varieties, how-
ever, appear; the basis-substance tending towards yellow, brown, or blue,
and the white lines being variously arranged.
It would be tedious to describe minutely these various arrangements:
let it suflSce that there are three principal, bu^ often mingled, plans.*
In some tumors, the bundles of white fibres tend to construct concentric
circles round one or many centries ; so that, in the section, we have a
vague imitation of the aspect of one or more intervertebral fibro-carti-
lages, the appearance of concentric curved fibres representing an ar-
rangement of layers successively inclosed, in the same involute manner
as I described in one of the varieties of fatty tumors (p. 397). These
are generally the hardest and least vascular of the fibrous tumors;
usually, too, they are spherical.
In another variety of the tumors, the white bands course in variously
sweeping curves and undulations, the components of the large bundles
diverging and interlacing.
In yet another variety, the fibres are less fasciculate, and appear as
if closely matted in a nearly uniform white substance ; and, in the ex-
treme specimens of this form, which are most commonly found on or in
the jaw-bones, a fibrous structure is scarcely to be discerned with the
naked eye : they look nearly uniform, glistening, pale or white, and
very firm ; but the microscope proves their identity with the other
varieties.
As on the exterior, so in sections, these tumors present various d^
grees of lobular arrangement. Some are uniform and scarcely parti-
tioned ; while others are formed in distinct and easily separable pieces;
and between these are numerous intermediate forms.
As a general rule, the vascularity of a fibrous tumor is in an bverse
proportion to its singleness and toughness of construction ; for the
bloodvessels, as in the natural fibrous structures, are distributed chieJj
or exclusively in the looser areolar tissue partitioning and investing tk
* See No8. 2666, 2671, 2672, in the Museum of the College of Surgeons.
FIBROUS TUMORS. 425
denser snbfitnnce. The tumors thus present various degrees of vascu-
larity. Some, when the vessels of the uterus arc fullj injected, appear
Btill quite white; but some appear as highly colored with the injection
as the uterus itself.*
In microscopic examination, one finds, among the fibrous tumors,
certun varieties of composition which are not always, if at all, expressed
in their more manifest characters. In alt, I believe, a large portion of
the mass consists of tissue resembling the tendinous or fibrous ; being
composed of exceedingly sleniicr, uniform, pellucid filaments, undu-
lating or crooked, more or less perfectly developed, and variously ar-
ranged.t This is the case in all parts of the tumor; in the more
bomogeaeous basis-substance as well as in the intersecting bands; the
microscopic differences between these parts consisting, I think, only in
the less or more regular arrangement of the fibrous structure or fibrous
appearance of the tissue. But in different specimens, or even in
different parts of the same, the tissue appears less or more perfectly
formed; so that, while in some, distinct filaments or undulating fasci-
culi may be dissected out, in others there is rather a fibrous appearance
than a fibrous structure. Commonly, too, one finds
nuclei or cytoblasts strewn through the substance of Pig. &3.t
the tumor ; the less abundantly, I think, the more per-
fect is the fibrous character of the tissue. But in all
these respects, there are not, I think, more or other
differences among fibrous tumors than in a series of
n&tnral fibrous tissues.
With these constituents other elementary tissues are
mingled in certain fibrous tumors. In those in the
uterus (just as in the uterus itself), smooth or organic
fflnscular fibres are more or less abundant.§ I have
Hot, indeed, seen such a specimen as would quite justify
the name of "muscular" tumors, assigned by Vogel:
but the mingling of the muscular fibres, in imitation of
* Romsikibly good specimene illusimiinji ihia poini me in the Muaeum or the MMdleeex
HmpitkL In Ihe Anatomical Muiaum of ihe University of Edinburgh are several beautiful
uiJFCtioiii of uteri with fibrous tumors connected to ihem. VeBieln o{ KJnie aiiie may be
•Mn ramifying beneath Ibe peritoneal coal of tlie tumore, and Ijinit in the lexer areolnr
pinilioni between Ibe lobules of mote compact Gbrea. But the eompact tissue itself is
(aoparatiTely pale, and itae entire substance of the tumors eiliibits a much smaller amoimt
oTnacularity than the uteii, to which Ihcy are connecled.
f Some of the best examinations are by Valenlio, in bis Repertorium ; and by Bidder, in
Walter, Oeber Bbriise Korper der Gel&rmutier, p. S7.
1 Fig. &S. Hinule structure of a uterine flbrous lumor. Narrow smooth muscular fibres
pnfBCt fhnn the edges of n fibrous tissue. Magnitled about 41)0 limes.
i The idenlity of structure between these lumnrB and the uterus itself is further proved
bf the interesting observations of Dr. Bristawe (Trans. Path. Soc., vol. iv, p. '216). He
fauid ibst during pregnancy the tumors both grew and cleveloped perfect smooth muscular
dbre* "idenlical in size, shape, general appearance and arrangcnient with those of the
meiine psrietM." Dr. Oldham basal
dMt after puturition tunM>r* of gi«at si
426 FIBRO-CYRTIC TUMORS.
the tissue of the uterus, is usual, if not constant, in these tumors.*
(Fig. 66.)
In the subcutaneous fibrous tumors, and in some, I believe, of the
uterine tumors, also,t elastic fibres, with all their fully developed
characters, may be intermingled with the more abundant fibrous tissue.
The structure of fascia is thus imitated ; and, if we were to call those
last mentioned "muscular** tumors, these should be named "fascial."
Again, in the fibrous tumors on bones, bone, in small plates or spicula,
is often present, or there may be mixtures of fibrous and cartilaginous
tissue. Possibly, also, other mixtures of tissues may occur in what we
commonly accept as fibrous tumors ; but I suppose that a general state-
ment may be truly made, to the effect that the common characters of
fibrous tumors, such as I just described, are usually modified towards
an imitation of tissues in or near which they are severally placed.
Their structural homology is thus complete ; and I presume they may
be equally similar in chemical properties. They yield gelatine on
boiling ; but I am not aware of any examination of their other consti-
tuents.
To the varieties of the fibrous tumor already named, two must yet be
added, depending on changes which we may regard as results of dis-
ease or degeneration. One consists in the formation of cysts, the other
in the deposit of calcareous and other salts in the substance of the
tumor; suggesting, severally, the names of the " fibro-cystic," and the
"fibro-calcareous,** tumor.
The formation of cysts is not rare in fibrous tumors, especially in
such as are more than usually loose-textured. It may be due to a local
softening and liquefaction of part of the tumor, with efiusion of fluid
in the afiected part ; or to an accumulation of fluid in the interspaces
of the intersecting bands ; and these are the probable modes of forma-
tion of the roughly-bounded cavities that may be found in uterine tu-
mors. But in other cases, and especially in those in which the cysts
are of smaller size, and have smooth and polished internal surfaces, it
is more probable that their production depends on a process of cjst-
formation, corresponding with that traced in the cystic disease of the
breast and other organs. The whole subject, however, relating to the
* Professor Forster has, in Virchow's Archiv, vol. xiii, p. 270, 1858, pointed out that, in an
example of that very rare form of "fibroid"' tumor, which grows in connection with ^
muscular coat of the intestine, the structure consisted, besides the bundles of fibrous tissue)
of numerous non-striped muscular fibres, which, just as in fibrous tumors of the uterus, were
arranged in larger and smaller bundles, crossing each other. The tumor was so closely
connected to the muscular coat of the ileum, that it could not be removed without injury »
the latter. The name Myoma has been proposed by Forster and Virchow, to distinguish
these tumors, in which the flat muscular fibres occur so abundantly, from the ordiiitry
fibrous tumors, formed only of connective tissue.
t See Bidder, in Walter, 1. c, p. 38. I have found, also, in a subperitoneal fibrous
tumor in the stomach, elastic fibres just corresponding with those of the natural subperito-
neal tissue.
FIBR0-CY8TIC TUMORS. 427
origin of the cysts, needs farther consideration ; and I will speak only
of the general appearance of the fibro-cjstic tumors.
First, then, we find examples of fibrous tumors thickly beset with
numerous well-defined and lined cysts. This appears to be the nature
of the "hydatid testis** described by Sir Astley Cooper. The speci-
mens that I have seen of it make me think that it is, essentially, a
fibrous or fibrous and cartilaginous tumor in the testicle, with more or
less of cyst-formation in the tumor. For, upon or around the tumor,
the seminal tubes or their remains may be traced outspread in a thin
layer, and without difficulty separable ; and the substance of the tumor
is a distinct mass of common fibrous tissue with or without imbedded
nodules of cartilage, and with a variable number of imbedded cysts,
filled with pellucid serous or viscid contents.* A similar condition may
be found, but is rare, in fibrous tumors of the uterus. It may be found
also, I believe, in fibrous tumors in nerves and other parts.
In another set of cases, we find one large cyst existing alone, or far
predominating over all the others, in a fibrous tumor. This is most
frequent in the tumors in the nerves, f and in the uterus. In the latter
organ it has peculiar interest, because the cyst, if it attain a great size,
may be mistaken and treated for an ovarian cyst. Several such cases
have happened. The preparation from one is in the Museum of the
College (No. 2657) ; the history of which, sent by Sir Everard Home,
is, that it is " A portion of a uterus, in which a very large encysted
tumor had formed. The patient had been twice tapped, and the cyst
emptied. The case was supposed to be an ovarian dropsy during life."
In another case, Mr. Csesar Hawkins, suspecting ovarian disease, drew
fifteen pints of fluid from a great cyst in a fibrous tumor of the uterus.^
The patient died a long time afterwards, and the specimen, which is in
the Museum of St. George's Hospital, shows an enormous fibrous tumor
in the side-wall of the uterus, having one vast cavity, and in its solid
part many small cysts.
With regard to the fibro-calcareous tumor, it is to be observed that
two methods of calcification exist ; a peripheral, and an interstitial. In
the former, which is the rarer, an ordinary fibrous tumor is coated with
* The results of Mr. Curling's "Observations on Cystic Disease of the Testicle'' (Med.
Chir. TraDS., vol. xxxvi, 1853) prove, that in the cases of fibrocystic tumor he examined,
the cysts were formed of dilated portions of the seminal ducts. They were lined with tes-
leUated epithelium, the cartilaginous and other growths which these tumors sometimes con-
tained being formed within these dilated ducts. Billroth s observations (Virchow's Archiv,
viii, 1855) also add to the probability of these cystic growths in fibrous tumors of the tes-
ticle being due to morbid states of the seminal tubes themselves, or of gland-like growths
from them.
t See Smith on Nenroma, p 0.
X Medical Gazette, vol. xxxvii, p. 1022. This specimen and others are described by Mr.
Preeoott Hewett in the London Journal of Medicine. See, also, on suppuration in these
cysts. Dr. Robert Lee, in the Med.-Chir. Trans., vol. xxxiii. Two remarkable cases of the
same kind are related by Schuh (Pseudoplasmen, p. 165). In one of them the huge cyst
in the uterine tamer produced the greatest enlargement of the abdomen that he ever saw.
428 FIBBO-OALCARBODB TDMOBa
a thin, rough, nodulated layer of chalky or bone-like substance.* In
the latter method, a similar substance is deposited more abundantly
throughout the tumor, and is usually so arranged, that, by maceration,
one obtains a heavy bard mass, variously knotted and branched like a
lump of hard coral. Such a specimen is in the College Museum (No.
226) : it was found in a graveyard, and was sent to Mr. Hunter as a
urinary calculus. It is an oval coral-like mass, about five inches long.
On analysis, it yielded 18*644 per cent, of animal matter, consisting of
gelatine, vrith a small proportion of albumen ; and its other chief con-
stituents were found to be phosphate and carbonate of lime, the pr(>-
portion of carbonate being greater than in human bone.
A similar, but larger, specimen is in the Museum of St. George's
Hospital ; and one yet larger in that of the Middlesex Hospital, vhieh
has been described, with a history full of interest, by Mr. Amottf
Now the change which ensues in these cases is not ossification ; true
„. g^ bone, I believe, is not formed in the fibrous
tumors of the uterus. The change is a cal-
careous degeneration, consisting in an amoi^
phous and disorderly deposit of salts of lime
and other bases in combination with, or in
the place of, the fibrous tisBne,§ It is repre-
sented, from Dusseau's plate, in the adjacent
figure (Fig. 56). The process is importanlj
as being the manifestation of a loss of tor-
mattve power in the tumor. The calcified
fibrous tumors probably never grow, and are
as inactive as the calcified arteries of oM
age. I)
'''3',.^'V'^"'('''B'f ' in' With these degenerations I may mention
W| P: ill!ll'. 'I(M' (though it has probably more of the natore
of a disease) a softcnirg of fibrous tnnion,
in which, quickly, and apparently in connec-
tion, with increased vascularity and congw-
tion they become oedcmatous, and then, u
their tissue loosens, become very soft, or even diffluent, or else break
up, and appear shreddy and flocculent. In this state the outer and
* Ai in Mu». Con. Surg., No. 2670.
t CBlcBieous deposil in a fibrous ulerii
t Me<iico-Chirurgical Tranaaelions, vol
tJniversily of Eilinburgh is a section of oi
entire slaie ii weighed 5 lbs.
J On the appearance of n cryiiiBlline form in tlie deposils, see Dusseau (Ondeix. vanbd
Beenweeftel en van Verbeeningen in zachle Deelen, p. bO).
11 A retiiariiBble exempliticalion is in Mr. Arnoit's case. In fbrtjr years, Ihe cakiSid
tumor did not more than double ila size.
iiii,p. 100. 1
rom Dusseau.
die Anatomical Museum otlhs
of tbese catcare
it, it looks aim
i-t like a mass of irory. In itt
JFIBRO-OALCABEOUS TUMORS. 429
less softened part of the tumor may burst, or they may separate or
slough.'*'
The most frequent seat of fibrous tumors is, beyond all comparison,
in the uterus. Indeed, we may hold that the fibrous uterine tumors
are the most frequent of all innocent tumors, if Bayle's estimate be
nearly true, that they are to be found in 20 per cent, of the women who
die after thirty-five years of age. But I shall not dwell on the fibrous
tumors in the uterus, fully described as they are by Dr. Robert Lee,
and other writers on uterine pathology. I will only say, that such tu-
mors may occur near, as well as in, the uterus ; but that, in respect of
this nearness, they are probably limited to those parts in which fibrous
and smooth muscular tissue, like that of the uterus, extends ; namely,
to such parts as the utero-rectal and utero-vesical folds, and the broad
ligaments.f
Next to the uterus, the nerves are the most frequent seats of fibrous
tumors. But of these, while I can refer to the splendid monograph by
Dr. Smith,| I will say only that, among the neuromata, the .fibrous tu-
mors reach their climax of multiplicity, existing sometimes in every
considerable nerve of the body, and amounting to 1200 or more in the
same person.§
So, too, having in view only the general pathology of tumors, and
not the study of their local relations or effects, I will but briefly men-
tion the fibrous tumors of bones ; referring for a larger account of these
to Bfr. Stanley's Treatise on the Diseases of the Bones, and to Mr.
Csesar Hawkins's Lectures on their Tumors. ||
* The whole of this process is extremely well described in Dr. Humphry's Lectures on
Surgery; Lect. xxvii, p. 130. Lately I have found imbedded in a large pendulous fibrous
uterine tumor, a distinct circumscribed fatty tumor, as large as a walnut, Mus. St. Barth.
Fibroiit tumors would also appear to undergo distinct fatty degeneration. In a specimen
which had been removed from over the leA tibia, examined some time ago by the editor,
the part of the tumor next the cutaneous surface was in a great measure converted into a
yellow mass, composed of fatty granules. And in the deeper part of the tumor in which
the fibrous structure was still preserved, distinct yellow lines, consisting of rows of fatty
granules, could be seen. These appeared to correspond in their position to, and consist of,
the degenerated corpuscles of the connective tissue.
f It appears, indeed, to be this mixed tissue to which the fibrous tumors particularly
attach themselves ; for they are in close relation with it in other parts besides the uterus ;
$, g, in the skin and the submucous tissue of the digestive canal and other parts.
\ On Neuroma : folio. Numerous cases are also collected by Moleschott in the Neder-
laodacb Lancet, Nov., 1845, and by Kupferberg: Beitrag znr GeschwQlste im Verlaufe der
Nerren, Mainx, 1854.
{ M. Lebert has related a case (Comptes Rendus de la Soc. do Biologic, t. i, p. 3) of a
woman, sixty-six years old, who had several hundreds of fibrous tumors in different parts of
ber subcutaneous tissue. But these do not seem to have been connected with nerves. A
case is related by Luschka in Virchow's Archiv, b. viii, p. 343, 1855, in which a fibrous tu-
mor as large as a small hen's egg, and completely isolable, was imbedded in the heart of a
ehild six years old.
I Medical Gazette, vols. xxi-ii~v.
480 SUBCUTANEOUS FIBROUS TUMORS.
Leaving these instances of fibrous tumors, the histories of which have
been so fully written, I will select, for the general illustration of the
whole group, some that are less generally studied; especially those
that are found in the subcutaneous tissue, and deeply seated near the
periosteum, or other fibrous and tendinous structures.
The aiibcutaneoiLS fibrous tumors^ to which those of the submucous
tissue closely correspond, pass, as I have already said (p. 407), within
sensible gradations into the fibro-cellular. Many may be found that
might deserve either name, just as there are many examples of natural
tissues with the same intermediate characters ; but it is not very rare
to find specimens with all the distinctive features ascribed to the fibrous
tumors of the uterus. These form firm, nearly hard, and tense, round
or oval masses, imbedded, single or numerously, in the subcutaneous
fat, raising and thinning the cutis. They may here attain an immense
size, as in a case from the Museum of Mr. Liston.* A tumor, weighing
upwards of twelve pounds, was removed from the front of a man's neck,
together with a portion of the integuments and platysma that covered
it. It was fifteen years in progress, and has an aspect such as, I
think, belongs only to a fibrous tumor. Specimens, however, of this
size are very rare ; they are commonly removed while less than an inch
in diameter.
In microscopic characters the subcutaneous fibrous tumors have the
general properties of the species, but they commonly contain elastic
tissue, and they are apt, I think, to be lowly developed, having only*
fibrous appearance, or even seeming composed of a uniform blastema,
with imbedded elongated nuclei, like the material for the formation of
new tendons.
A peculiar and important character in these fibrous tumors is, that
though they may be completely isolated in every other part, they often
adhere closely to the lower surface of the cutis, and that, if in any de-
gree irritated, they soon protrude through it, and form vascular masses,
"fungous growths,'* as they are called. When this happens, they
may bleed profusely, and in a manner which, I believe, is not imitated
by any other innocent tumor.
A woman, 52 years old, was under Mr. Stanley's care with a tumor
that projected through the integuments in the inner part of the thigh,
its base being imbedded deep in the subcutaneous tissue, and its pro-
truding surface raw and ulcerated. The origin of this tumor was uncer-
tain, but it had existed more than nine years ; it had grown quickly,
and had began to protrude within two and a half years. From its ul-
cerated surface hemorrhage frequently ensued ; and the patient stated
that at one time two quarts of blood flowed from it. The tumor was
excised, and large vessels that entered its base bled freely in the opera-
* Mu8. Coll. Surg., 222.
DEEP-SEATED FIBROUS TUMORS. 481
tion. It appeared to be a well-marked specimen of a soft and lowly-
developed fibrous tumor.
A similar case was under my care in a woman 27 years old. The
tumor, of three years* growth, and protruding over the front of the
tibia, was similarly ulcerated, and used often to bleed ; sometimes it
bled largely, and once as much as half a pint of blood flowed from it.
This also, on removal, appeared to be a fibrous tumor.
Through the kindness of Mr. Birkett, I saw a specimen, from a much
more formidable example, of the same fact. A woman, 60 years old,
had a large pendulous tumor in the front wall of her abdomen, suspended
just below the umbilicus, and reaching half way to her knees. Its
surface had a very inflamed appearance, and the separation of a slough
from its posterior part gave issue to such hemorrhage as proved quickly
fatal.
The tumor is a large, heavy mass, which was attached to the sheath
of the rectus. It is everywhere firm and tough, except where its sub-
stance appears to have been broken by blood issuing from numerous
large vessels that traverse it. Mr. Birkett, who examined it soon after
the patient's death, found its texture certainly fibrous.*
The fibrous tumors that occur in or near accumulated fibrous tissues
are well exemplified, medically, by some of those of the dura mater,
and, surgically, by those which maybe found at the tarsus or metatarsus,
imbedded among the ligaments and other deep-seated parts. Some
well-marked specimens are in the Museum of the College. One,t from
the collection of Mr. Langstafi*, is an oval tumor, six inches long,
fixed to the periosteum of the tarsal bones and to the adjacent parts,
and filling the sole of the foot from the os calcis to the bases of the first
phalanges. It was removed, with the foot, from a nobleman, 35 years
old, in whom it had been observed gradually increasing for thirty years.
It has all the general aspects of the fibrous tumor, as typified in those
of the uterus.
A very similar specimen is shown in a tumor growing over the whole
length of the dorsal aspect of the metatarsus ;J and with these may be
mentioned one§ which has some historic interest, for it was removed
from the Hon. William Wyndham, the associate and friend of Pitt, and
Fox, and Burke, — " the model of the true English gentleman;*' When
he was 60 years old, and an invalid, he exerted himself very actively
one night in saving from fire the library of a friend. During his exer-
tions he fell, and struck his hip ; and from that injury the tumor ap-
peared to derive its origin. It grew quickly, and in ten months it seemed
necessary to remove it. Mr. Wyndham submitted to the operation, his
biographer says, " with neither hope nor fear ;" and it would be difficult
• This specimen was sent to the Museum of Guy's Hospital by Mr. Nason.
f No. 220. The other half of the same is in the Museum of St. Bartholomew's Hospital,
Series zxxv, No. 9.
X Mus. Coll. Surg., 219. $ Mus. Coll. Surg., 218.
^^^^^■ilescribe so briefiy a more unfavorable state of minil. The operation
^^^^^Kts performed b; Mr. Ljiin. The tumor was attached to the capsule
^^^^B of the hip, and was with difficult;
^^^^B removed. At first all went on well ;
^^^^V /^ but then, it is said, symptomatic
^^^H m-''ik- ^-^ fever came on, and death occurred
^^^H ^r ' Ai I '^^ ^^^ ^^ixteenth day. The tumor
^^^B ^g S'. L ta ^'*^' ^^ ^^' ^y**^^^^'^ request,
^^H ^^^^- <^ ' ' placed in the Museum of thi;i Col-
^^B ^HBmH l^g^i i^"*' I have had it sketched,
^^B ^KS^^^a. because it might be signslized as
^H ^H^HB^....-— "'*^ '^'' ^^- '"°^^ characteristic ex-
;iiM).](-sor its kind.
I iiiiglit add several to these cases,
i.iit theae may suffice for illustra-
. !ii>nsf.f the fibrous tumors connected
iMth the deep-seated fibrous tissues.
All iJio specimens that 1 have seen
have presented the strong while
bauds intersecting a grayish or dull
white basis-Hubstance, the charao- —
teristic Brmness, heaviness, and ten — .
sion; all, in microscopic examina.-
js structure or appearance; all bar ^
tion, have 6hu(\u iIil tun^L
yielded gelatine in boiling.
The favorite seats of the fibrous tumors of bone and pcnoeteum ar^
about the jaws; on other bones they are very rare. The College Stti-
seum is, I suppose, eminently rich in fibrous tumors connected with the
. jaws, containing as it does the chief of those that were removed by &fr.
Liston; a series illustrative at once of his admirable dexterity, and nf
his sound knowledge of pathology.
These tumors of the jaws may, to both touch and sight, present tbe
ordinary characters of the fibrous tumors, as alrewly described. Tli<!J
usanlly approach the round or oval shape, but are generally knobbed, i
or superficially lobed, or botryoidal, as some have called them. Thcj J
are firm, dense, and heavy. On sectiou. however, the majority of thetn.r
I think, are more uniform than the fibrous tumors of other parts. TteM
are generally almost uniformly white, and scarcely intersected by iiam
distinct fibrous bands, except such as may divide them into lobei
Many of them also present, in their interior, minute spicula of compH
white, bony texture.
As to situation and connection, the fibrous tumors of the jnws ri
be found isolated and circumscribed, growing within the jaw, divorl
II ; from ibe ccisp ilesciibeil ii
FIBBOUB TPMORfl OK BOSS AND PBBIOBTECII. 488
and expanding its walls, and capable of enuoleation* (Fig. 58 a) ; but,
in a large nomber of these tumors, the periosteum, with or without the
bone itself, is involved or included in the outgrowing mass (Fig, 58 b).
Pig. S8.t
The difference is illustrated by the sketches (Fig. 58). In the case of
the upper jaw, either the periosteum, or the fibro-mucous membrane of
the antrum or nasal walls, or both of these, may be included in such a
tumor. In all cases the tumor lies close upon the bone, and cannot be
cleanly or without damage to it separated, except on the outer surface :
commonly, indeed, bony growths extend from the involved bone into
the tumor ; and sometimes the greater part of the bone is as if broken
up in the substance of the tumor.
In all these characters of connection, the fibrous tumors on the ex-
terior of the jaws and about other bones resemble outgrowths : they are
as if some limited portion of the periosteum were grown into a tumor
overlying or surrounding the bone. The character of outgrowth is in*
deed generally recognized in the epulis, or tumor of the gums and
alveoli ; but I believe Mr. Hawkins is quite right in the view which he
has expressed, that the fibrous epulis should be regarded as a tumor
growing, like most of the other fibrous tumors, from the bone and peri-
oateum, and continuous with them. J That it is prominent and lobed
■ Fot mch ea»en nee the MiiKiims of the College Hnd of Si. Bailholamew's and Gny'i
Hoipilalii Stanle]r,Illu!itmiionB,pMfi,Fig. 8; Waril, Proc. ofihe Pathol. Soc., Nov. K>, IMS.
t Fig. S8 A. FibrouB minor within Ihe ramus of the lower jnw, diapaiting aii'l eitend-
ing iu walli. B. A gimilBr lunnoc outgrowinK upon the lowoc jaw. Both are represented
in lection, one half of the natural size, fWim specimens at Si. BanUolomew's. Both con-
riMed of perfect and unmixed fibroiia tissue.
J I tayjibmu tpub't, because Krowihs may be found resembling common epulis in many
characters, yel differing in »ome, and especially in microscopic siruciure. M. Lebert classes
rpali) with flbro-plaslic tumors, nnU I shall refer in Ihe next lecture to specimens present-
ing the srnicture to which he gives that name ; but more of those which I have examined
were of a pureljr fibrous texture. The difference may be imporianl in surgery ; for there is
alwaya uncertainly about the operations for epulis ; perhaps because among the flrm-lobed
tratBTOwihs from the gums and jaws, to all of which the same name is ajiplied, iliere are
two or more hinds of tumors, with as many different properties. The lecture of Mr.
Hawhini (Medical Gazette, vol. ixxvii, p. lOS'J) is the best study on the subject of epulis,
Mr. Birkfltl tell* me be has Ibnnd the glaiids of the gum much developed in some instances
oTTuinon tba« named.
434 FIBROUS TUMORS IN THE EARS.
is because it grows into the open cavity of the mouth ; and it resembles
gum only because it carries with it or involves the natural substance of
the gum.
I will refer to but one more set of cases of fibrous tumors ; those,
namely, that occur in the lobules of the ears. These are, indeed, tri-
vial things in comparison with the tumors of the jaws, yet they have
points of interest, in that they grow after injuries, and are very apt to
recur after removal. They are penalties attached to the barbarism of
ear-rings. Shortly after the lobules of the ears have been pierced, it
sometimes happens that considerable pain and swelling supervene.
These are apt to be followed by a more defined swelling in the track of
the puncture ; and this swelling presently becomes a well-marked fibrous
tumor in the lobule of the ear. There may be, perhaps, some doubt
whether the growth be a proper tumor or a cheloid growth of the cica-
trix-tissue formed in the track of the wound ; but it has the aspect of
a distinct fibrous tumor, and the skin appears unafiected.
In one case, of which the specimens were presented to the Museum
of St. Bartholomew's Hospital* by Mr. Holberton, a tumor, such as I
have described, formed in the lobule of each ear of a young woman, a
few months after they were pierced for ear-rings. Both the lobules were
cut ofi" with the tumors ; but, in or beneath one of the cicatrices, a simi-
lar tumor formed shortly afterwards. This was excised ; and in the-
ten years that have since elapsed, there has been no return of the dis —
ease.
In another case, under the care of Mr. Benjamin Barrow, two sucl
tumors formed in the same ear after puncture. One of these was cim^^
away, the other was left : a third grew, and the excision of the whol. e
lobule was necessary for the complete extirpation of the disease.
Similar cases are recorded by Bruch,f Venzetta,J and others ; hxit
the histories of the cases are so like these that I need not detail them.
Among tumors so diverse in their seats and relations as the fibrous
tumors, there are perhaps few things relating to their life that can be
stated as generally true.
In the uterus many may exist at the same time : the whole wall of a
uterus maybe crammed with them, while others project ft-om it into the
peritoneal cavity. As Walter and others have observed, when a fibrous
tumor fills the cavity of the uterus, or projects from it into the vagina,
it is not usual for another to be found in the walls. Such cases do in-
deed occur, but they are comparatively rare. It is yet much more
rare for fibrous tumors to be found in any other part at the same time
as in the uterus. I find but one such case recorded ; a case by Dr.
* Ser. XXXV, No. 24.
f Die Diagnose der bosartigen GeschwQlste, p. 208.
^ Annates de Chirurgie, Juillet, 1844.
OARTILAOIKOUS TUMOR&; 485
Sutherland,* in which, with several fibrous tumors in the uterus, one
was found in the groin of a lunatic 42 years old. But such a case is a
most rare exception to the rule ; or, indeed, may be more like an ex-
ample of the rule, if the tumor were connected with the round ligament,
and the tissue therein continuous with the uterus.
In the nerres, as in the uterus, a multiplicity of fibrous tumors may
be found ; but, so far as I know, the rule of singleness generally pre-
vails in every other part liable to be their seat.
Their growth is generally slow and painless. It is often very slow,
so that tumors of thirty or more years' standing are found still far
short of the enormous dimensions of some of the last species. But no
general rule can be made on this point, especially since the rate of
growth is influenced by the resistance offered by the more or less yield-
ing parts around.
The extent of growth appears unlimited; and among the fibrous
tumors are the heaviest yet known. They have weighed fifty, sixty,
and seventy pounds. The tumor that induced Walter to write his ad-
mirable essayt weighed seventy-one pounds. He refers, also, to one
of seventy-four pounds, and to one described in an American journal
as having been estimated at one hundred pounds ; but he asks of this,
perhaps impertinently, whether it were weighed also (aber auch ge-
wogen ?).
In relation to the degeneration and diseases of fibrous tumors, I need
add nothing to what has been said concerning the formation of cysts,
the calcification, and the process of softening or disintegration. And
respecting their nature, there can be no doubt that, in general, they are
completely innocent.
LECTURE XXVI.
CARTILAGINOUS TUMORS.
Thb name of Cartilaginous Tumors may be given to those which
Miiller, in one of the most elaborate portions of his work on Cancer,
has named Enchondroma.| Either term will sufficiently imply that
the growth is formed, mainly, of a tissue like cartilage ; and I would at
once point out the singularity of such tumors being formed, and grow-
ing to so great a size as I shall have to describe, lalthough cartilage is
♦ Proceedings of the Pathological Society, vol. ii, p. 87.
t Ueber fibrdse Korper der Gebarmutter. Dorpat, 4to., 1842.
^ Other names employed are Osteochondroma, Chondroma, Benign Osteo-sarcoma. The
tenn osteo-sarcoma cannot be too entirely disused ; it has been more yague than even Sar-
coma, having been employed indiscriminately for all tumors, of whatever nature, growing
in or upon bones, provided only they were not entirely osseous.
486 OARTILAOINOUS TUMORS.
not commonly formed for the repair of its own injuries, nor, at least in
man, in a perfect manner, for the repair of the injuries of bone.
The cartilaginous tumors are found, in the large majority of cases,*
connected with the bones and joints.* However, they occur not rarely
in soft parts, completely detached from bone. Thus, in the pure form,
or mixed with other tissues, they are met with in the testicle,t mammary
gland,! subcutaneous tissue, § and lungs, || and in the soft parts near
bones ; but among all the soft parts their favorite seat appears to be the
neighborhood of the parotid gland. The greater part of the solid tumors
formed in this part have cartilage in them.
Cartilaginous tumors that are connected with bones may, like fibrous
tumors (Fig. 58), occur in two distinct positions ; namely, within the
walls, or between the walls and the periosteum : rarely they grow in
both these positions at once. When they are within the bones, they are
isolated and discontinuous, and are surrounded by the bone-walls, which
may be extended in a thin shell or capsule around them, or may be
wasted and perforated by them. When they grow outside the bones,
they are generally fastened to the subjacent bone-wall by outgrowths of
new bone ; the periosteum, greatly overgrown, invests them, and pro-
longations from it towards the bone appear to intersect them, and divide
them into lobes. When they grow among soft parts, they have a well-
formed connective tissue capsule, which is commonly more dry and glis-
tening than that of most innocent tumors.
In any of these situations, cartilaginous tumors may be either simple
or complex, conglobate or conglomerate, if we may adopt such terms;
i. e. they may be composed of a single mass without visible partitions,
or, of numerous masses or knots clustered, and held together by their
several investments of areolar tissue. According to these conditions,
they present a less or more knotted or knobbed surface ; but in either
state they aflfect the broadly oval or spheroidal shape (Fig. 68). Tf
* Those referred to as connected with the joints are the cartilaginous masses that are
found pendulous or loose in joints. They have suflicient characters in c(»mtnon with these
tumors to justify their enumeration in the list ; yet they are in so many respects peculiar,
that they need and usually receive a separate history. The best account of them, and of
their probable origin in the villi of synovial fringes, may be gathered from Bidder, in Henle
and Pfeufers Zeitschr. B. iii; Rainey, in Proc. Pathol. Soc., ii, p. 140; and Kolliker, Mik-
rosk. Anat., ii, p. 324.
t Mus. Coll. Surg., Nos. 2384-5-6, &c. ; Mus. St. Bartholomew's Hosp., Ser. xxriii. No. 17,
and Appendix ; and several in the Museum of St. Thomas's Hospital. See also Mr. Gam-
jee's pamphlet, on a Case of Ossifying Enchondroma in the Testicle of a horse. Also a case
related in Trans. Med. Chi. Soc., vol. xxxviii.
J Aatley Cooper, Diseases of the Breast, p. 64 ; Moller, On Cancer, p. 149, No. 13, from a
dog; Mus. St. Bartholomew's, Ser. xxxiv, No. 13, from a biich.
i Rokitansky, Pathol. Anat., B. i, p. 261 ; Lebert, Abhandlungen, p. 195.
H Mus. St. Bartholomew's, Pathol. Appendix; Rokitansky and Lebert, I. c. Fdrster in
Virchow's Archiv, vol. xiii, p. 106.
1[ In the Anatomical Museum of the University of Edinburgh are several very illustra-
tive specimens of cartilaginous tumors. In most of these tlie cartilage is arranged in the
form of separate nodules, varying in size from a pea to a bean, each nodule beiog invested
OARTILAOINOUS TUMORS. 487
To the touch, cartilaginoos tumors may be very firm or hard, espe-
cially when they are not nodular and their bases are ossified. In other
cases, though firm, they are compressible, and extremely elastic, feeling
like thick-walled tensely-filled sacs. Many a solid cartilaginous tumor
has been punctured in the expectation that it would prove to be a cyst.
The knife cuts them crisply and smoothly ; and their cut surfaces
present, in the best examples, the characters of foetal cartilage ; bright,
translucent, grayish, or bluish, or pinkish-white, compact, uniform.
Usually, each separate mass or lobe is without appearance of fibrous or
other compound structure ; but, sometimes, the cartilage looks coarsely
granular, as if it were made up of clustered granules. This is, I think,
especially the case in the cartilaginous tumors inclosed in the bones of
the hands and fingers, especially in such of them as are soft. In other
cases, when the cartilage is very firm, it may be opaque or milk-white.
In different examples of cartilaginous tumor there are great varieties
of consistence or firmness. Some appear almost difiluent. or like
vitreous humor ; some are like the firmest foetal cartilage ; and all in-
termediate gradations may be found : but, with the exception of the
cartilaginous growths that are pendulous or loose in joints, I have never
seen any present such hardness, dulness, or yellowness, as do the na-
tural adult cartilages of the joints, ribs, or larynx.
As, in all general appearance, the material of these tumors, in its
usual and most normal conditions, is identical with foetal cartilage, so is
it, I believe, in its development, and, as Miiller has shown, in its che-
mical characters.* The microscopic characters, also, of cartilaginous
tumors agree, speaking generally, with those of foetal cartilage; yet
there are several particulars to be observed concerning them, and, espe-
cially, the diversity of form and arrangement that may be seen in the
microscopic constituents of even different parts of the same tumor
needs mention.
This diversity of microscopic forms is enough to baffle any attempt
to describe them briefly, or to associate them with any corresponding
external characters in the tumors. The most diverse forms may even
be seen side by side in the field of the microscope. But this diversity
18 important. It has its parallel, so far as I know, in no other innocent
tumor ; and the cartilaginous tumors form perhaps the single exception
to a very generally true rule enunciated by Bruch ;f namely, that it is
bj a looae capsule of connective tissue. In some of these specimens the vessels have been
filled with a red injection, which has passed into the substance of the tumor, being situated
in m distinct, though not very abundant, capillary plexus lying in the partitions of connective
tissue between the cartilaginous nodules. It was undoubtedly from the blood which circu-
lated through these capillaries, that the nutrition of the tumor was effected. In the prepa-
rations the red lines of injected vessels present a striking contrast to the opaque white no-
doles of cartilage.
* The encliondromata of bones, he says, always yield chondrine ; while those of sol^
parts may yield either gelatine or chondrine. (On Cancer, p. 124.) The whole account of
dieir analysis is very amply given by him.
f Die Diagnose der bosartige Geschwiilste.
488 mOROSCOFIO STBUCTURBS
a characteristic of the cancerouB tumors, and a distinctioo between
them and others, that they present, even in one part, a maltiformity of
elementary shapes.
The diveraity of microscopic characters extends to every constitoeDt
structure of the cartilage in the tumors. I will state the general and
chief results of the examinations of fifteen of the recent specimens,*
of which I have made notes, and the drawings from which the annexed
figures were copied.
(1) In regard, then, to the basis or intercelfular substance: It is
variable in quantity, the cells or nuclei in some specimens lying wide
apart (Fig. 59), in some closely crowded (Fig. 61, &c.) : it varies in
Fig. 69.t
Fiy. 60. t
consistence, with all the gradations to which I have already referred:
and, in texture, in some specimens, it is pellucid, hyaline, scarcely
visible , in some, dim, like glass breathed on ; in many more, it \»
fibrous in texture or in appearance
(Figa. 59, 60). Most cartilaginom
tumors, inileed, might deserve to be
called fibro- cartilaginous. It is sel-
dom, and, I think, only in the firmest
1 joinlB; of which, indeed,™
with a tew imbeilde<l caniJage-cells. Fiom
• These are eiclmive of specimen* of loose ci
acconnt will be given in this leclute.
t Fig. SQ. Tuned, pale, fllanient.
a lumor over ihe parotid gland.
t Fig. 60. Sirongeranil deniet fibro-carlilaginouBtislue; many ofthe oarlilaginomeelli
having granulaied nuclei. From a lumor over iho paiotid (jlaml, magnified -100 limei.
J Fig. 61. Gtotips of canilage.cells, clustered in a portion of a tumor on the pliataMof
a finger. Many of (he cells are only drawn in outline ; the groups are inlemecied by bands
of lough fibrous tissue ; some of the cells present double or triple con ion r- lines; most of the
nticlei are large and granular. Magnified about 40u limes.
II Fig. 6^. A group of large carlilage-cells from ihe same i many conlaining Iwo or th««
nuclei, of which some have acquired the character of inclosed cells.
OF CARTILAQIHOUa TUHOKS. 489
pacta or BpeoimetiB, that the subetance between the cartilage-cella haa
the atrong hard-lined fibrous testure which belongs to the chief natural
fibrona cartilages ; jet it haa generally a fibrous texture. The fibres
are, or appear, usually soft, nearly pellucid, and very delicate ; some-
timea they appear tufted or fasciculate (Fig. 59) ; sometimes they
encircle apacea that contain each a large cartilage-cell, or a cluster of
cells or nuclei (Fig. 61) ; sometimes they form a fasciculated tissue, in
vhich cartilage-«ell8 lie elongated and imbedded (Fig. 60) : most com-
monly of all, I think, they curve among the cells, as if they were
derived from a fibrous tranaformation of an intercellular hyaline sub-
atsnce (Fig. 68).
Fig. 68 • Fig. es A.
(2) Yet greater varieties may be found in the characters of the car-
tilage-cells-t In plan of arrangement they may be irregularly and
widely scattered, or closely placed, or almost regularly clustered with
fibrous tissue encircling them (Figs. 59, 61, 62). In single cells there
are varieties of size from ^iD'h to -,eniitl' of an inch. And there are
yet more varieties of shape; some have the typical form of healthy
preparatory cartilage- eel Is, being large, round, or oval, or variously
shaped through mutual pressure, faintly outlined, with aingle nuclei,
and clear contents (Fig. 63) ; and some arc like normal compound car-
tilage-cells (Fig. 62). But, with various deviations from these more
norisal characters, some cells have hard dark outlines ; and some are
bonndedby two,three, or four dotted or marked concentric circles, as if
* Fig. S3. Group or carlitago-cells from a lumor in Ibe itbia. Fine fllBmenioiu liisue
encircles, nod inlerTsnei betweeo, linglr cells. Some of tbe nuclei of llie cells contain oil-
pulicles; nnd some of tbe same (in Fig, 63 a) bIiow, appaieully, (he piocesa of assuming the
WellkM or branched fotm. Magnilled aboul 400 times.
f I rataJD this name, although the obaervaiions of Bergmann (De Canilaginibus, 1G50)
■Dd otfaera show that ll is difficult, in some cases, lo delecmine ihe nature of tbe cell^sinleiits,
and that Ibeir nuclei maj be more like cells, or, having bad tbe cliaracters and relations of
unelei, may acqnira those of included nucleated cells. Taking, as [be type of caililege-MUi,
(he elements of Ihe cborda doriatii, I think we shall least orieu eir if we keep the term all
for those elementar]' stiuciures in otbsi cartilages wl
eboiiia, in tbeir flue clear outline, and tbe pellucid oi
440
MIOROSGOPIG STRUOTURBB.
the cell-walls had become laminated (Figs. 61, 62) ; others appear with-
out any defined cell-walls, as
Pig. 64.* jf ^jjgy ^ere mere cavities
hollowed oat in the basis-sab-
stance; and, in other in-
stances, the cell-walls and
their contents, down to the
nucleus, appear as if they
were completely fused with
the basis-substance, so that
the nuclei alone appear to be
imbedded in the hyaline or dimly fibrous material. These last two states
appear to be connected with very imperfect development or with degene-
ration; for I have seen
^^«- ^^t them, I think, in only soft
cartilage, or in such as
showed other distinct signs
of degeneration. In many
such cases, also, the nuclei
are so loosely connected
with the ba^is-substance,
that large numbers of them
float free in the field of the
microscope.
(3) The varieties of the nuclei in the cartilage of tumors are not less
than those of the cells. Some are like those of the normal cartilage ;
round or oval, clear, distinctly outlined, with one or two nucleoli (Fig.
62). But some appear wrinkled or collapsed, as if shrivelled ; some
contain numerous minute oil-particles, representing all the stages to
complete fatty degeneration, and the formation of granular bodies (Figs,
60, 63) ; some are uniformly but palely granular, like large pale cor-
puscles of lymph or blood ; some are yet larger, nearly filling the cells,
pellucid, like large clear vesicles with one or more oil-particles inclosed;
and some have irregularities of outline, which are the first in a seriefl
of gradational forms, at the other extremity of which are various stel-
late, branched, or spicate corpuscles (Figs. 63 a, 64, 65).
I have not been able to discern any constant rule of coincidence be-
tween these forms of nuclei and the various forms of cells, nor between
either and any of the enumerated appearances of the intercellular or
basis-substance. All modes of combinations have appeared among
them ; only, on the whole, the completely developed cells have the
* Fig. 64. Free nuclei : some simple, and some enlarged, and variously beset with
branching processes. From a cartilaginous tumor under the angle of the lower jaw. Mag-
nified 400 times.
t Fig. 65. Similar nuclei variously distorted and shrivelled. From a mixed cartilaginoM
tumor over the parotid ; similarly magnified.
i
OARTILAOINOUS TUMORS. 441
best nuclei, and the degenerate or imperfect of both are asually in
company.
The last-named nuclei, with irregular outlines, deserve a more par-
ticular description, both because they are, so far as I know, found in
no normal cartilage in any of the vertebrata, and because their imita-
ting, in some measure, the forms of bone-corpuscles, might wrongly
suggest that they have a constant relation to the ossifying process.
They were first described, I think, by Miiller ; and have since been
noticed in cartilaginous tumors by Mr. Quekett, and many others. I
have examined them in seven cases ; and, to show that they are not
peculiar to one form of cartilaginous tumor, I may add that, of these
seven, one was a great tumor encircling the upper part of the tibia, one
a growth on the last phalanx of the great toe, one a mixed tumor in
the articular ead of the fibula, one a very soft tumor in the subcutane-
ous tissue on the chest, and three were mixed tumors over the parotid
or submaxillary gland.
The phases of the transformation by which they are produced appear
to be, as represented in Figs. 63 a, 64, 65, that a nucleus of ordinary
form, or with one or more oil-particles, enlarges and extends itself in
one or several slender, hollow, and crooked processes, which diverge,
and sometimes branch as they diverge, towards the circumference of
the cell. Such nuclei may be found within the cells (Fig. 63 a), or
within cavities representing cells whose walls are fused with the inter-
cellular substance ; but much more commonly it appears as if, while
the nuclei changed their forms, the cells and the rest of their contents
were completely fused with the intercellular or basis-substance, so that
the nuclei alone appear imbedded in the hyaline or pale fibrous sub-
stance. The nuclei thus enlarged may appear like cells, and their
nucleoli may be like nuclei. But although, at first, as we may sup-
pose, the nuclei, as they send out their processes, may enlarge and
retain the round or oval form of their central parts or bodies, yet they
afterwards lengthen and attenuate themselves, so as to imitate very
closely the shapes of large bone-corpuscles or lacunae ; or they elongate
and branch, or shrivel up ; and in these states, lying in groups, they
have the most fantastic appearances (Figs. 64, 65). In these various
states the nuclei are often loosely connected with the basis-substance ;
so that they are easily removed from it, or are found floating on the
Seld of the microscope, as nearly all those were which are here drawn.
Now, as I have said, corpuscles like these exist permanently in no
lonnal cartilage yet examined, in man or any of the vertebrata.* If,
Jlien, heterology of structure were indicative of malignancy, the tumors
iiat contain these corpuscles should be malignant ; but there are no
* The only natural cartilage yet known as possessing these corpuscles is, I believe, that
£ thie cuttle-fish (Quekett, in HistoL Catal. of Coll. of Surg., pi. Ti, Fig. 7) ; and it is at least
nterettiiigi and may be importantly suggestive, to observe that the morbid structure, devia-
ing from what \m natural in its own species, conforms with that of a much lower creatuie.
29
GROWTH, ETC., IN CARTILAGINOUS TUMORS. 448
idmg the upper two-thirds of a girl's tibia, grew to a circnmference
iro feet in about 18 months. Gluge'*' also mentions a case in which,
boy 14 years old, a cartilaginous tumor on a tibia grew in 8^ months
lie sise of a child's head, and protruded, and caused such pain «nd
ie, that amputation was necessary.
need only refer to the importance of these cases in their bearing
he diagnosis of tumors, and as exceptions to the general rule, that
malignant grow more rapidly than the innocent.
Q extent of growth, the cartilaginous tumors scarcely fall short of the
)Q8. Mr. Frogleyt has related two cases of tumors of enormous size,
one, the patient was a young woman 28 years old, and the tumor,
learly five years' growth around the shaft of the femur, extended
n the knee-joint to within an inch of the trochanters, and measured
rly three feet in circumference. It was a pure cartilaginous tumor,
its whole central part was soft or liquid, and many of the nodules
rhich it was composed had the character of cysts, through such cen-
Boftness as I shall presently have to describe. The limb was re-
red near the hip-joint, and the patient has remained in good health ^
seventeen years since. |
n the other case by Mr. Frogley, the patient was a lady 37 years
, and the tumor had been growing eleven years ; it was 20^ inches
iircumference, and exactly resembled that in the former case. The
intation of the limb was equally successful.
lie tumor in Mr. Lloyd's case, to which I have just referred, mea-
dd 24 inches in circumference. But all these are surpassed by an
atnce related by Sir Philip Crampton, in which a tumor of this kind
roonding the femur, and soft in all its central parts, measured no
I than 6^ feet in its circumference.
rhe only change of cartilaginous tumors which can be spoken of as
evelopment, is their ossification : and this is, I believe, in all essential
1 minute characters, an imitation of the ossification of the natural
tilages.
But the more general or larger method of ossification must also be
lerred. Ossification may ensue, I suppose, in any cartilaginous tu-
r; but it is rare or imperfect in those that grow within bones, and
fet more imperfect, and is like the deposit of amorphous calcareous
tter, in those that lie over the parotid gland. It is best seen in those
•t Ue upon or surround the bones ; and in these, two methods of ossi-
ition may be noticed,
n one method, ijne ossification begins at the surface of the bone,
Pttboligische Anatomie, Lief. iy.
lfadioo>Chinirgical Transactions, vol. xxvi
I hsTe to thank Mr. Frogley for affbrUing me this information, and Mr. Lane for an
rtofutj of exhibiting at the Lecture the remarkable specimen obtained by the operation,
low preferred in his Mnseum.
444
GROWTH AKD OTHBR CHANQBS
where the cartilagioous tnmor rests od it, and thence the new-fonsed
bone grows into the cartilage. Thus, the ossification ma; tsatce pro-
gress far into the substance of the cartilage ; and the tumor may ap-
pear like an outgrowth of bone covered with a layer or outer crust of
cartilage, on which the periosteum is applied. Or, extending yet farther,
the cartilage may by this method be wholly ossified, and the cartilagin-
ous may be transformed into an oaseous tumor.
In the other method of ossification, the new bone is formed in the
mid-substance of the cartilage. In a large tumor the process may com-
mence at many points, and, extending from each, the several portions
of new bone may coalesce with one another, and with that formed in the
first method, like an outgrowth from the surface of the original bone.
Indeed, this twofold method of ossification is commonly seen io the lurge
tumors that surround long bones.
The ossification ensuing in several points, and thence extending, 19
plainly, in these tumors, an imitation of the natural ossification of tii^
skeleton from centres iix
^'s- «■• each of its constitnent
parts. Sometimes, in-
deed, this natural pro-
cess is imitated with sii-
gular exactness. Tfani,
in the College Huseiii%
No. 207, is a portion of*
large tumor which w«
taken from the front of
the lumbar vertebra of
a soldier. Half of it is
cartilaginous, and half is
medullary cancer. The
cartilaginous portion
consists of Dumerou
small nodules, of varioni
shapes, each of which is invested with a layer of connective tisane, u
its perichondrium. In many of thcac, a single small portion of yello*
cancellous bone appears in the very centre, each nodule ossifying fron
a single nucleus or centre, as orderly as each cartilage of the fcetil
skeleton might oaaify,
I shall speak in the next lecture of osseous tumors, and, among
them, of those that are formed by these methods. It may therefore
suffice for the present to say that, in nearly all cases, the bone formtd
in cartilaginous tumors consists of cancellous tissue, with marrow or
medullary substance in ita interspaces; and that when the osaificatioti
of the tumor is complete, the new cancellous tissue is usually invested
I. Seciion of the caitilBginoui ind cancerouB lumoi deiccibedin the ti
dcdasil
IN OARTILAQINOUS TUMORS. 445
with a thin compact layer or outer wall of bone, which, if the tumor
haye grown on a bone, becomes continuous with the compact tissue of
that bone.
The principal defect or degeneration noticeable in cartilaginous tu-
mors is manifested in their being extremely soft, or even liquid ; a clear,
yellow, or light pink, jelly-like, or synovia-like material appearing in the
place of cartilage. I call it a defect or a degeneration, because it is not
always certain whether it is the result of cartilage, once well formed,
having become soft or liquid, or whether the soft or liquid material be
a blastema, which has failed of gaining the firmness and full organiza-
tion of cartilage. It is quite probable that the same defective structure
would be found in arrests of development as in degeneration ; and the
history of the cases agrees herewith. The conditions in which extreme
softness is sometimes found can leave little doubt, I think, that it is in
these cases a degeneration, — a liquefaction of that which was once more
perfectly nourished ; but, in other cases, the softness of structure ap-
pears to have characterized the growths from their earliest formation ;
such, probably, was the case of which the history is told on the next
succeeding page ; but in many cases we have no guide to the interpre-
tation of the peculiarity.
The soft material of cartilaginous tumors is like melting, transparent,
yellowish, or pale pinkish jelly ; or like a gum-like substance, or like
honey, or synovia, or serum. Such a material may occupy the whole
interior of a cartilaginous tumor, one great cavity, filled with it, being
found within a wall of solid substance.'*' Or the whole mass of tumor, f
or its exposed surface, J may be thus soft or liquid. Often, too, we may
trace in individual nodules of a cartilaginous tumor, a process of what
I suppose to be central softening, by which, perhaps, the formation of
the great central cavities of the large tumors is best illustrated. Thus,
in the tumor of cartilage and medullary cancer, of which I have already
spoken, as illustrating the process of ossification from a centre in each
nodule, there are many nodules, in the centre of which, instead of bone,
small cavities full of fluid are seen. So, too, in a large cartilaginous
tumor, growing on the pelvic bones of a man forty years old, a portion
of which was sent to me by Mr. Donald Dalrymple, I found a large
number of distinct nodules, each with a central cavity full of honey-like
fluid ; and the state of the cartilage around these cavities, its softness,
the fusion of its cell-walls, and their contents, with its hyaline basis,
and the sparing distribution of nuclei in it, make me believe that the
softness and liquefaction were the results of a degenerative process.
* As in Mr. Frogley*8 case; and as in many nodules of the tumors, No. 207 and others,
in the Museum of the College of Surgeons.
f See a drawing of one in the band, and a specimen in Ser. ] 115, in the Museum of St.
Bertbolomew's, and the specimen giren to the Museum by Mr. Bickersteth, and described
OD the next page.
X Mos. CoH. Sorg., No. 206.
446 GROWTH AND OTHER CHANGES
When the softening may be safely regarded as degenerativOy it is
still, often, very difficult to say to what the change is due. In some
cases it appears connected with the great bulk of the tumor, and the
hindrance to the sufficient penetration of blood to its central parts.
Hence it is, I think, proportionally more frequent in the large than in
the smaller tumors. In some cases it may be due to exposure of the
tumor, as in the instance of a cartilaginous tumor which grew from the
sacro-iliac symphysis and adjacent bones, and projected into the vagina
of a woman thirty-four years old.* But in many more cases we are
unable to assign a reason for such softness.
The central softening of single nodules of cartilaginous tumors may
extend to the formation of cysts ; for when the whole of a nodule ia
liquefied, its investment of connective tissue may remain like a cyst
inclosing the liquid. This change was shown in the same tumor as
illustrated the central ossification and the central softening. And it
was not difficult to trace in it what appeared like gradations from cen-
tral to complete liquefaction, and from a group of cartilaginous nodules
to a group of cysts with tenacious fluid contents.
When extensively softened or liquefied, or when almost wholly trans-
formed into cysts with viscid contents, the cartilaginous tumors are
very like masses of colloid cancer ;t so like, that the diagnosis, without
the microscope, might be nearly impossible. Such a tumor was sent to
me by Mr. E. Bickersteth. A woman, forty-five years old, had two
tumors, one on the eminence of the right frontal bone, the other half
an inch below the right clavicle. The former was globular, as large as
a walnut, and fixed to the bone. It felt soft and doughy, but at its
base and around its margins it was hard. The latter was about twice
as large, subcutaneous, and freely movable ; it felt like a fatty tumor,
except in that it was not distinctly lobed, and was less firm and con-
sistent than such tumors usually are. Both tumors had been gradu-
ally increasing for eight years, and had been painless. The patient's
mother had died with hard cancer of the breast.
The tumor below the clavicle was removed. It was an oval mass,
invested by a thin connective-tissue capsule, partitions from which
intersected it, and divided it into lobes of unequal size, distinct, but
closely packed. They all consisted of a soft, flickering, yellow, and
pale ruddy substance, widely intersected with opaque-white lines. The
substance was extremely viscid, and could be drawn out in strings, stick-
ing to one's fingers, like tenacious gum. Its general aspect was very
like that of a colloid cancer, but it had no alveolar or cystic structure,
and it was an isolated mass, not an infiltration. Portions lightly pressed
(for it needed no dissection for the microscope), showed as in the an-
* Mu8. Coll. Surg, No. 206.
t I believe they have been often described as such. I think, too, that some of them are
included by Vogel in his group of " gelatine tumors " (GallertgeschwQlste), of which h«
says gelatiniform cancers are the most frequent form.
IK CARTILAGINOUS TUMORS.
447
nexed figure (67), together with a small quantity of loose connective
tissue and fat, a peculiar filamentous tissue in curving and interlacing
Pig. 67.
bundles, and in separate very long and very tortuous, or curled fila-
ments, or narrow flat bands (a). The latter appeared as peculiar pale
filaments, about TsivD^^ of &^ ^^<^^ i^ diameter ; in shape and mode of
coiling resembling elastic fibres, but not having dark edges, and extend-
ing to an extreme length. Such fibres lay imbedded in a pellucid viscid
substance, and more abundantly scattered in the same were various
corpuscles (b). Of these some were simple, others of more complex
forms. The former were, generally, nearly round, dimly nebulous,
with one or two shining particles, but (unless in a very few instances)
without nuclei. These seemed to be free nuclei, of which many had
grown to an unusual size, and measured joVd^^ ^^ ^^ ^^^^ i^ diameter.
The more complex had the same texture as these, and seemed to be
also altered nuclei, and resembled most nearly the stellate nuclei of
more ordinary cartilaginous tumors. They generally had an oval, or
round, or angular body or central part, from which slender processes
passed out. These followed various directions. Some were short ; some
branched once or more; some were extremely long, and appeared to
connect adjacent corpuscles, or to be continued into some of the tortu*
oas bands or filaments, like which, as they extended farther, they be-
came pale, clear, and finely edged. The chief and extreme forms are
sketched, and many intermediate between these existed.
Since the operation the patient has remained well, and the tumor on
the head has been stationary for four months ; so that, thus far, the
history has confirmed the only opinion I could form of so strange a
tamor, namely, that it was composed of immature soft fibrous cartilage,
not only arrested, but in a measure perverted in its development.'*'
* In a letter dated December 12th, 1862, Mr. Bickersteth states that he has not seen or
heard anjrthing of this patient since her discharge from the hospital.
448 CARTILAGINOUS TUMORS OF THE BONSS.
The softened central parts of cartilaginous masses are apt to be
affected with rapid sloughing or suppuration. Such an eyent occurred
in Sir Philip Crampton*s case, already quoted, and in one, presenting
many features of great interest, which was under Mr. Lloyd's care, at
St. Bartholomew's Hospital.* A girl, 14 years old, was admitted with
a very large tumor round the upper two-thirds of the tibia. It had
been growing for 18 months, and shortly before her admission, without
evident cause (unless it were that it had been punctured), the integu-
ments over it began to look inflamed and dusky. The limb was ampu-
tated almost immediately after her admission ; and the tumor presented
in its anterior a large cavity with uneven broken walls, filled with
brownish serous fluid of horribly offensive putrid odor. The inner sur-
face of the walls of the cavity appeared also putrid, and gases, the
products of the decomposition, were diffused in the areolar tissue as far
as the middle of ^he thigh.
Other changes of a degenerative character may be sometimes ob— -
served in cartilaginous tumors. Parts of them may appear grumous oim
pulpy, and of an ochre yellow color.f This is probably a fatty degen^^
ration of their tissue. And, sometimes, as I have said, their ossification
is so imperfect as to be more like a fatty and calcareous degenerationi^
in which their substance becomes like fresh mortar, or soft chalk, ancS
when dry, is powdery, and white, and greasy. J
It may serve for additional illustration of this general pathology of
cartilaginous tumors, if I describe now some particular form of them.
I have said that they chiefly affect the bones. The bones of tie
hands are their most frequent seats ; and next to these, the adjacent
extremities of the femur and tibia, the parts which, for some inexplicabie
reason, appear to have in all the skeleton the least power of resistance
of disease. After these, the humerus, the last phalanx of the great toe,
the pelvis, and the ribs, appear most liable to cartilaginous growths;
and after these, the number of cases is as yet too small to assign an
order of frequency, but there is scarcely a bone on which they have
not been seen.
Of the cartilaginous tumors of the large long bones I need say little,
having drawn from them the greater part of the general description.
Only, the relations of the growths, according to the part of the bone in
or near which they lie, may be worth notice.
When, then, the tumor grows at or about the articular end of a large
long bone, it is almost wholly placed between the periosteum and the
bone. Here it usually surrounds the bone, but not with a uniform
thickness ; and the thin wall of the bone wastes and gradually disap-
* It is fully reported in the Lancet, December, 1850. The specimen is in the Museam
of the hospital.
t Mus. Coll. Surg., No. 200.
X Mus. Coll. Surg., No. 204. Rokitansky, B. i, p. 262. Dr. Humphry has particularly
described this change in his Lectures, p. 142.
OAKTILAOISOUB TUMORS OF THB BONBB.
449
Fig. 88.
peftra u if it were eroded, or as if it changed its form, becoming can-
cellooB, and then groving into the tnmor. I have never seen anch a
tnmor eneroaching on the articular surface of a hone ; bnt it may grow
np all abont the borders of the joint, and surround them. A striking
example of these relations of the cartilaginons tumor to the bone on
irhich it grows is in one of the best and most characteristic specimens
in the College Museum ;* a cartilaginous tviinor of the humerus, removed
in an smpatation at the shoulder-joint by Mr. Liston. His sketch of
it is here copied. The patient was a naval surgeon, and the tumor had
been growing for nearly forty years.
The mass it now forms is nearly
ten inches across ; it surrounds the
apper three-fourths of the shaft of
the hnmems, and nearly surmounts
its articular surface ; and it shows
abundant isolated nodules, partial
central ossification and central soft-
ening, and the growth of bone from
the cancellous tissue of the humerus
into the tumor. It shows, too, very
well, how bloodvessels and nerves
are imbedded in the inequalities of
mch tnmors, witbont being involved
by them.
It is extremely rare, I think, for
a cartilaginous tumor to grow with-
in the articular end, or in the
medullary tissae near it, in a large
long bone. A striking specimen,
however, was presented by Mr.
LangatoD Parker to Mr. Stanley.
It was removed, by amputation of
the lower part of the leg, from a
young gentleman in whom it had grown slowly, and hud distinctly pul-
■sted. The lower end of the fibula is expanded and wasted by a growth
of cartilage, mixed with a substance such as will be described in the
next lecture, as the characteristic material of the fibro-plastic or mye-
l<Md tumors. The growth is rather larger than an egg, and is invested
by the remains of the expanded fibula, and by the periosteum ; and
the relations of the chief bloodvessels make it probable that the pul-
sation felt during life was derived from that of the vessels within the
tnmor.t
* Mot. Coll. Surg', No. 779, The pHiieni recovered from the operation, but died two
DMMitlu aftertrirds with Jiteaie of the ctiett. Tbe specimen ia represented in Ui. Liiion't
Praolicml Surgerjr, p. 374, from which tbe sketch (Fig. 6ti) u drawn.
t TbB spocimea is in the Museum of Si. Bailbolomew's Hotpilal. No. 763 in the Mus.
450 OABTILAGINOUS TUMOBS OF THE BONBS.
When a cartilaginous tumor grows at the middle of the shaft of a
large long bone, it is, I think, usual to find coincidently both an exter-
nal and an internal growth. Cartilage lies outside the shaft, beneath
the periosteum ; and another mass may fill the corresponding portion
of the medullary canal. Then, in the concurrent growth of the two
masses, the wall of the bone between them wastes or is broken up, and
they may form one great tumor set between the portions of the shaft*
These are the cartilaginous tumors which most imitate the progress of
malignant disease. They are indeed very rare ; but the chance of the
existence of such a one, where we might be anticipating a malignant
tumor, is always to be added to the motives for amputation in cases of
tumors round the shafts of these long bones.
Such are some of the chief facts to be noted about the cartilaginous
tumors on the large long bones.
On the jaws these tumors are, I believe, very rare. I know but one
specimen on the upper jaw alone ; a great tumor, portions of which are
preserved in the Museum of Guy's Hospital, and of which the history,
by Mr. Morgan, is in the Hospital Reports.
On the lower jaw, such tumors appear prone to acquire a peculiar
shape, affecting the whole extent of the bone. One of the most re-
markable tumors in the Museum of the Collegef is of this kind. The
patient was a lady 39 years old. The tumor had been growing eight
years ; it commenced as a small hard tumor just below the first right
molar tooth, and gradually enlarged till it inclosed the whole jaw, ex-
cept its right ascending portion. It measured two feet in circumference,
and six inches in depth, and the patient died exhausted by want of
food, which she was unable to swallow, and by the ulceration of parts of
the tumor during the last two years of her life.
M. LebertJ has recorded a case in which a tumor like this was re-
moved by Dieffenbach. In three successive operations he removed it
by instalments, and the patient finally recovered.
The cartilaginous tumors that grow about the cranial bones and the
vertebrae show, in a marked manner, that reckless mode of growth (if I
may so speak) which is more generally a characteristic of malignant
tumors. They grow in every direction ; pressing, and displacing, and
Coll. Surg.y is an ossified cartilaginous tumor within the upper end of the fibula. In the
Museum of St. Thomas's Hospital is a most remarkable instance of cartilaginous tumon
growing, at once, in the scapula, the upper part of the humerus, and the lower part of Ae
same. In tlie last-named part the cartilage lies within the thinned walls of the bone. The
case is described by Mr. William Adams, in the Proc. of the Pathol. Soc., vol. ii.
* A specimen of this form is in the Museum of St. Bartholomews in and upon a femur,
in Ser. i, No. HI; and one of very large size, around and in the upper third of the femur,
is in Guy's Hospital Museum. One also is mentioned by Mr. Hawkins as occurring in the
middle of the shaft of the humerus (Medical Gazette, vol. xxv, p. 476). Mr. Syme also re-
cords two cases in the Ed. Med. Jal., Jan., 1854, p. 4. The tumors in both cases occurred
in the humerus, in which bone, next to the maxillary bones, he thinks this form of tumor
most frequently appears.
t Nos. 1034 and 201. J A-bhandlungen, p. 197.
CABTILAGINOUS TUMORS ON THE HANDS. 451
leading to the destrnction of, important parts, and tracking their way
along even narrow channels.
In St. Bartholomew's is a tnmor,* composed, for the most part, of
cartilage, which grew in connection with the bones of the face and head
of a lad 16 years old. It involved both superior maxillary bones, ex-
tended into the left orbit, and through the left side of the base of the
skull into its cavity, compressing the anterior lobes of the cerebrum :
it was also united to the soft palate, and protruded the left nostril, and
the integuments of the face.
The commencement of a similar growth is probably shown in a spe-
cimen in the College Mu8eum,t in which, together with changes effected
by the growth of nasal polypi, one sees the ethmoid cells completely
filled with firm semi-transparent cartilage, a mass of which projects in
a round tumor into the upper part of the left nasal fossa.
And here I may adduce, in proof of the tracking growth of the car-
tQaginous tumors, the case of one| originating in the heads of the ribs,
which extended through the intervertebral foramina into the spinal
canal, where, growing widely, and compressing the spinal cord, it pro-
duced complete paralysis of the pelvic organs and the lower extre-
mities.
The cartilaginous tumors of the hands deserve a special notice.
As many, I believe, as forty cases might be collected from various
records, in which the bones of one or both hands, and sometimes of the
feet also, have been the seats of numerous cartilaginous tumors. Seve-
ral of these cases were collected by John Bell ;§ many more by MUller,||
who drew, indeed, from these cases the greater part of his general ac-
count of enchondroma ; and many more might now be added to the list.
Four admirable specimens of the disease are in the Museums of the
College and of St. Bartholomew's.
The first of these, Tf from the collection of Sir Astley Cooper, consists
of the amputated fingers and heads of the metacarpal bones of a girl 13^
years old. Tumors had been growing in these bones for eleven years ;
and now there are eleven or twelve, from half an inch to an inch and a
half in diameter, and all formed of pure cartilage.
The second was presented to the Museum of St Bartholomew's by
Mr. Hodgson.** It comprises the right hand, and the little finger of
* Mas. St Bartholomew's Hospital, Ser. xxxv, No. 47. Drawn in Mr. Stanley^s Illastra-
tkms of Diseases of the Bones, pi. xvii, fig. 4.
t Mas. Coll. Surg., 2199.
} Mus. St. Bartholomew's Hospital, Ser. i, No. 115.
$ Principles of Surgery, vol. iii, p. 65.
I On Cancer. Whenever the statements made by Miiller respecting the general charac-
ters of cartilaginous tumors differ from the account here given, the differences may, I think,
be explained by his taking for the type the tumors of the hand. This alone could have
made bim regard so little the ossification of cartilaginous tumors.
f Mas. Coll. Surg., 775.
** Described in the Pathological Appendix to the Catalogue.
462
CABTILAaiNODS TDMORS ON THH HAHDS.
the left band, of a lad 14 years old, in whom, without any known cause,
the tumors had been growing from early childhood. In the right hand,
the metacarpal bone of the thumb contains two tumors ; and of the fore
finger three or four tumors, of which the smallest is an inch, and the
largest is three inches in diameter ; the first and second phalanges, also,
of the fore finger, cont^n tumors ; the middle finger appears normal ;
the third finger has one tnmor in its metacarpal bone, one in its first
phalanx, and two in its second phalanx ; the little finger has as many,
in corresponding positions. On the left band the only tumor was that
in the first phalanx of the fore finger.
K third preparation* contains the fore and little fingers removed by
Mr. Lawrence from a healthy lad IT years old. He had on his left
hand four, and on his right hand six tumors ; bnt those that were re-
moved were alone troublesome and increasing. They varied from one
inch and a half to one-third of an inch in diameter, were all covered
with healthy smooth skin, and appeared to grow from the interior of
the bones. No account could be given of their origin, except that they
began to grow when he was five years old ; and some grew more quickly
than others. In both fingers a formation of cartilage had occurred in
the metacarpal bones and the second phalanges, which was attended
with scarcely any swelling : indeed, till the operation was being per-
formed, these bones were not supposed to be the seats of diseaae, thoDgh
their medullary cavities were quite full of cartilage.
The fourth specimen,
Pig. 60.t
* Mus. St. Bartholomew's, Palhol, Apperalii
t Fig. 60. Hnnd with cartilaKinous lumors, described a
the DBluial size.
here sketched, is, I believe,
the most remarkable jet
seen. I received it from
Mr. Salmon, of Wedraore.
It is the right hand of i
laborer, 56 years old, from
whom, when be was 16
years old, the fore finger
of the left hand was re-
moved with a tumor weigh-
ing 2 lb. 5oz. The little
fingerof thesamehandhu
a tumor about as large as >
walnut: the whole length of
his left tibia has irregular
nodules on its anterior and
inner surface, and some
enlargement exists at hi>
left second toe. On the
right hand, which Mr. Ssl-
Reduced lo one-SAh of
OABTILAGIKOUS TUMORS ON THE HANDS. 468
mon amputated, there are tamers on every finger, and one spheroidal
mass nearly six inches in diameter, in which the second and third fingers
appear completely bnried, the walls of their phalanges being only just
discernible at the borders of the mass that has formed by the coalition
of tnmors that-grew within them.
The disease which these specimens illustrate begins, I believe, ex-
clusively in the early period of life ; during childhood, or at least
before puberty, and sometimes even before birth. It occurs, also,
much more frequently in boys than in girls. One or more, or nearly
all, of the phalanges or metacarpal bones of one or both hands may en-
large slowly, and without pain, into an oval, or round or heart-shaped
swelling. When such swellings are grouped, they produce strange
distortions of the hands, making them look like those of people who
have accumulated gouty deposits ; or, as John Bell delights to repeat,
like the toes and claws of sculptured griffins. They may greatly elon-
gate the fingers, but they more commonly press them asunder, limiting
and hinderipg their movements.
There is no rule or symmetry observed in the affections of the hands,
except that the thumb is less frequently than the fingers the seat of
growths.
In the large majority of cases, if not in all, each tumor grows within
a bone, the walls of which are gradually extended and adapted to its
growth. And this position within the bones is the more remarkable,
because, in the cases of single cartilaginous tumors of the fingers or
hands, the growth takes place not more, but rather less, often within
than without the bone ; these single tumors commonly growing, as those
of the larger long bones do, between the periosteum and shaft. '*'
Thus, growing within the bones, the cartilaginous tumors may be
sometimes found, even in the same hand, in all stages of growth. One
phalanx or metacarpal bone may have its medullary cavity full of car-
tilage without any external appearance of enlargement ; another may be
slightly swollen out at one part, or in its whole periphery ; another so
extended on one side, or uniformly, that its walls form only a thin shell
around the mass of cartilage ; in another the cartilage may have grown
out through holes absorbed in the walls of the bone, and may then
have spread out on its exterior ; while from another it may have pro-
truded through apertures even in the integuments, gradually thinned
and ulcerated :f or, as the specimen sketched in Fig. 69 shows, we may
find not only such a protrusion through integuments, but two originally
distinct tumors, growing out beyond the limits of their respective bones,
and coalescing in one huge mass. In cases of this kind, the cartila-
♦ M1W.C0U. Surg., No. 772-3.
f A good case illustrating the last-mentioned fact is represented by Professor Miller, in
bit Principlea of Surgery, p. 450, 3d ed. The tumor on the back of the metacarpus weighed
Ibnrtaeu pounds, and aAer protrusion, bled frequently. John Bell also has recorded several
•uehcBBet.
464 CARTILAGINOUS TUMORS
ginous mass in each bone usually appears as a single tumor, with very
delicate, if any, partitions. It may have a coarsely-granulated aspect,
but it is rarely divided into distinct nodules, or strongly intersected.
Its exterior is adapted closely to the interior of the shell of bone, but
is not continuous with it, except by bloodvessels. It rarely ossifies, ex-
cept in a few small scattered cancellous masses in its mid-substance.*
And it is worth observing, that the tumors often project on only one
side of a bone ; for when this happens in the metacarpus, it is often
very hard to tell which of two adjacent metacarpal bones should be cut
out in case of need.
The cases of this singular disease have shown great diversity as to
the course of the tumors, and in their modes and rates of growth ; some
making progress, some remaining stationary ; and I believe it has often
happened that at the time of manhood all have ceased to grow. Bat
in regard to all these questions, important as they are, we are yet in
need of facts.
It would be easy, and as vain as easy, to speculate on the meaning
of such a disease as this. I believe no reasonable explanation of it
can as yet be given, unless it may be said that these are the results of
an exuberant nutrition similar to that which in the embryo may produce
supernumerary limbs, but is here more disorderly and less vigorous.
The only remaining instances of cartilaginous tumors to which I shall
refer are those that grow near the parotid, or, much more rarely, near
the submaxillary gland. f Some of these are formed of pure cartiliage,
and might be taken as types of the cartilaginous tumor ; but more are
composed of cartilage, or fibrous cartilage, variously mixed with other
tissues, and especially with what appears to be an imperfect or a per-
verted glandular tissue. Whichever of these forms they may have,
they are commonly imbedded in the gland. They are sometimes wholly
surrounded by the gland-substance, but much more commonly are more
or less deeply imbedded in it, and covered with its fascia.
These tumors are generally invested with tough capsules of connec-
tive tissue, which, though sometimes loose, are more commonly bo
closely attached to the surrounding parts that it is difficult to dissect
them out. And the inconvenience of this is not a little increased by
the frequent contact of branches of the facial nerve, which are apt to
adhere very closely to the deep part of the tumor, or to be imbedded
between its lobes, or may even stretch over its surface. J
* Specimens of ossification are in the College Museum, No. 785-6.
f These are grouped by Rokitansky as the third variety of the Gelatinous Sarcoma, with
a recognition of their affinity to Enchondroma. Mr. Syme names them " Fibro-c»rtilagiQOUS
Sarcoma" (Principles of Surgery, vol. i, p. 89). The first good description of them was
given by Mr. Lawrence (in his paper on Tumors, already often quoted). Mr. Ctesar Haw-
kins described them, for the most part, as " conglomerate tumors."
X The imbedding of important parts in a cartilaginous tumor needs to be remembered.
In the Museum of St. George's Hospital is a specimen of this kind, about seven inches in
OTIB THB PAROTID GLAND.
465
The general aspect of these tamors depends mach on the proportion
in which the cartilage and their other component tisanes are mixed.
When they are of pare cartilage, or when the cartilage, or delicately
fibrous cartilage, greatly predominates,
they may present all the general charac- ^5- ™-*
ters that are already described. Such
a case is illustrated by that to which,
among all the specimens of the kind,
the primacy belongs. It was removed
by Mr. Hnnter, and is enough to prove
the skill and boldnesB as an operator
which some have denied him. The case
was that of a man, thirty-seven years
old, who, sixteen years previously, fell,
and bruised his cheek. Shortly after
the injury, the part began to swell, and
the swelling regularly increased for four
or five years, when he again fell and
struck the swelling, which, after this,
extended, especially at its lower part
and base. It seemed quite loose, and
movable without pain. Mr. Hunter ex-
tirpated it, and with complete success.
It weighed 144 ounces, and measures in
its chief dimensions 9 inches by 7. It
presents a striking instance of the con-
glomerate cartilaginous tumor, consisting of numerous round masses of
pale, semi-transparent, glistetiing cartilage, connected by their several
areolar investments ; and its exterior is deeply lobed and nodulated.
Its apparent composition is confirmed by the microscopic examinations
of Mr. Quekett,t who found it composed of cartilage, in which some of
the intercellular substance is homogeneous, and some finely fibrous.
But when in these tumors the cartilage is equalled or exceeded in
qosntity by the other tissue of which they may consist, we may find
the same oval and nodular or lobed form, and the same hardness or
firmness and elasticity, but they appear on section, opaque white or
cream-colored, and less glistening than cartilage.| Generally, these
dimmelsr, wbicb wa> sent to the Museum with tbe history, that, in lemoving it from the
deep tiuuei of the ihigh, the remoral ailery was cut ectoss where pusing ihroutih its Bub-
* Fig. TO. MiDUle stmctures of a miieil cartilaginous tumor over the parDiicI gland.
In Ibe upper sketch, a group of wiiherod, stellale, canilage- nuclei are encircled with fibrous
liwue. Others lie Dear tbe group ; while, equally near, are well-formed cartilage-cells, and
gTDDpa of small nuclei or nucleated cells, like those of gland'Slmctu res. In the lower sketch
timilkT eorpnsclee «« grouped as in the acinus of a gland.
t Histological Catalogue, vol. i, p. Ul.Ag. S3.
X Tlwy an among tbe tnmors which one dnds desonbed ai like tnniipi or like poutoe*.
456 CARTILAGINOUS TUMORS OVER THE PAROTID GLAND.
mixed tumors appear uniform ; but, sometimes, portions of purer carti-
lage are imbedded in the mixed tissue, and obscurely bounded from it.
In microscopic characters the cartilaginous part of these tumors has,
I believe, no peculiarity ; different specimens may offer all the variety of
forms to which I have already referred.
The tissue mixed with the cartilaginous is at present, I think, of
uncertain nature. In several cases I have found it, for the most part,
present a lobed and clustered structure, with fibrous-looking tissue en-
circling spaces that are filled with nuclei and cells. These inclosed
spaces look so like the acini of a conglomerate gland, that they seem
to confirm the opinion one might form from its general aspect ; namely,
that it is an imitation of gland-tissue. And this is confirmed by the
character of the cells within the seeming acini ; for they have the gene-
ral traits of gland-cells. They are usually small, round or oval, flat-
tened, dimly granular, with nearly round, pellucid nuclei with nucleoli.
They lie either like a thin epithelial lining of the spaces I just men-
tioned, or else they are clustered within them ; or they may be irregu-
larly grouped through the whole substance of the tumor ; and in all
cases abundant free nuclei like their own are mingled with them.*
Such are the most general characters of these cells ; but they are
apt to vary from them, being more angular, or bearing processes, or
being attenuated or caudate. Even if we may consider them as imita-
ting gland-structures, yet it may be a question whether they are related
to the adjacent parotid gland, or to lymphatic gland. It would be easy
to discriminate between the elements of the parotid and of a lymphatic
in their natural state ; but a morbid imitation of either of them may
deviate far enough to be as much like the other. And it is well to re-
member that these tumors have exactly the seats of naturally existing
lymphatic glands, and are often closely imitated by mere enlargements
of these glands ; so that, possibly, future researches may prove that
they are cartilaginous tumors growing in and with a lymphatic gland
over or within the parotid or submaxillary gland.
In general history, especially in their slow and painless growth, the
absence of any morbid influence, except that produced by pressure on
* Although the tissue mingled with the cartilaginous may not unfrequently simulate
gland tissue, yet the star-like and spindle-shaped cells, imbedded in a jelly-like or bItdkxX
fluid mass, so often found in these tumors over the parotid , belong, without doubt, to that
embryonal connective or mucous tissue, which has already been referred to (pp. 402, 415),
as occasionally entering into the structure of other tumors. This form of tissue blends in
various ways, as Billroth more especially describes, with the cartilaginous, and together
with it may constitute entire tumors over the salivary glands. FOrster thinks that from what
he has seen (Atlas, Taf. xix, p. 1), he is justified in stating that this mucous tissue may be-
come converted into cartilaginous, the soft mucous basis-substance gradually passing, with-
out any sharp lines of demarcation, into cartilaginous basis-substance, in which the cartilage
cells possess a spindle or star-like form with anastomosing processes. Much additional in-
formation respecting the structure of salivary glandular tumors may be found in a paper hj
Billroth, in Virchow's Archiv, vol. xvii, p. 357, 1859.
RBCURREKT CARTILAGINOUS TUMORS. 457
the BurrouDdiDg parts, the absence of proneness to foul alceration, and
of tendency to return after removal ; in all these, the tumors over the
parotid agree, I believe, with the other forms of cartilaginous tumors.
I will therefore not delay to relate cases of them ; but will draw towards
conclusion by referring to some points connected with the general his-
tory and nature of the whole group of cartilaginous tumors.
First, then, concerning their origin : They begin, in a large majority
of cases, in early life ; between childhood and puberty. Yet they may
begin late in life. I saw one on the hand, which had been of no long
duration when it was removed from a man 70 years old; another, grow-
ing in the humerus, and described by Mr. W. Adams,* had grown
quickly in a man of 61 ; another began to grow at the same age, in a
woman's thumb. f Most commonly, also, those in or near the parotid
appear in or after middle age.
Then, concerning their nature : they may be regarded as, usually,
completely innocent tumors, and yet there are some cases recorded, in
which we must believe that, after a cartilaginous tumor has been re-
moved, another has grown in the same place. I saw one such in a
woman 30 years old, in whom, soon after the removal of one tumor
from the parotid region, another grew and acquired a great size. This
was an unmixed cartilaginous tumor; and I believe the first was of the
same nature. Dr. Hughes Bennett^ has related a case in which Mr.
8yme removed a cartilaginous tumor of the arm by amputation at the
shoulder-joint. Subsequently, the patient, a girl, 14 years old, died
with tumors in the stump and axilla. Mr. Liston removed a portion of
the scapula, with a great tumor in its spine and acromion, which I have
no doubt is a soft and cartilaginous tumor.§ Three years afterwards
the patient died, with what is described as a return of the disease.
Mr. Fergusson showed at the Pathological Society a fibro-cartilaginous
tumor|| of the lower jaw, which had grown twice after the complete
removal of similar tumors from the same part. In the Museum at
Guy's Hospital, also, there is a cartilaginous tumor growing from the
angle of the lower jaw into the mouth, which is said to have grown
after complete removal of a similar tumor with the portion of lower
jaw to which it was connected. Lastly, Professor GlugeTf records two
cases, in which we must believe that recurrence of cartilaginous tumors
ensued after complete removal. In one, a cartilaginous tumor, of 18
years' growth and 9J pounds weight, over a man's scapula, clavicle,
and neck, returned in the ribs, and destroyed life in a year and a half.
* Proceedings of the Pathological Society, ii. 344. f Lebert; Abhandlungen, p. 101.
X On Cancerous and Cancroid Growths, pp. 108 and 258.
I College Museum, No. 781.
I Mr. Simon examined it with the microscope, and found it formed of well-marked car-
titege, with a fibrous basis.
f Atlas der pathologischen Anatomic, Lief, iv ; and Pathologische Histologie, p. 67.
30
458 MIXBD CARTILAGINOUS TUM0B6.
In another, a similar tumor of the orbit returned two and a half years
after removal.*
We must conclude, I think, from these cases, that, although the
general rule of innocence of cartilaginous tumors is established by their
usual history, by numerous instances of permanent health after re-
moval, and by cases in which, after death, no similar growths are found
in lymphatics or internal organs, yet recarrence after operatiops may
ensue. I think that when this happens it will generally be found that
the recurring growths, if not the original growths also, are soft, rapid
in their increase, and apt to protrude and destroy adjacent parts ; as if
we had, again, in these, an instance of that gradual approximation to
completely malignant characters, of which I spoke in the last lecture.
I think, too, that we shall find that these soft cartilaginous tumors
which are apt to recur, or of which more than one exists in distant parts
in the same patient, affect particularly those who are members of can-
cerous families (see p. 446).
In connection with these points, I may refer to some additional facts
in the pathology of cartilaginous tumors.
First, many may exist in the same person ; secondly, they are some-
times hereditary ; thirdly, they may extend themselves to more or less
distant parts by means of the lymphatics ;t fourthly, they are not
unfrequently mingled with cancerous growths.
* Virchow relates a case (Archiv, B. v., p. 216) in which tumors recurred aewen tioMfio
the scapula, and were removed ; an eighth then grew, and proved fatal. These tumors con-
tained many cartilaginous elements, so that they had an affinity to the cartilaginous group of
tumors ; but from the number of cysts in them it was hard to say with which they ought lo
be classified.
f Mr. Paget has recorded in the Trans. Med. Chir. ^oc, vol. xxxviii, 1855, a ve^yr^
markabie case of cartilaginous tumor of the right testicle, in which the cartilage extended
itself into other and distant parts by means of the lymphatics. It occurred in a man at 37.
When the testicle was removed, it was found to contain tortuous, cylindriform, and knotted
pieces of cartilage, some of which could be seen to be contained in tortuous and commuiu*
eating canals, which they tightly filled ; others were close packed, and imbedded in a tough
filamentous white connective tissue, but it is extremely probable that these also bad grown
in canals, with the walls of which they had finally coalesced. These canals were sbovB
to be lymphatic vessels, several of which could be traced passing from tlie testicle along the
cord, and containing similar cartilaginous growths. The lymphatics were, by these growthi
within them, rendered so tortuous and enlarged as to form a series of tumors, like a chuB
of diseased lymphatic glands. Portions of the lymphatic vessels between the growths wen
dilated into cysts, filled with a pellucid fluid, probably lymph, detained in the vesseb
through the obstruction presented by the growths. The patient recovered remarkably well
from the operation, but a few weeks afterwards he died, showing signs of disease in no
organs but the lungs. On making a post-mortem examination, two dilated and tortnoai
lymphatic vessels could be traced upwards from th6 internal abdominal ring, along with the
spermatic bloodvessels. They were filled with cartilage, and became connected with •
swelling, along with which they adhered closely to the lower part of the vena cava inieriai^
reaching nearly to the origin of the renal veins. This swelling was probably a diseued
lymphatic gland. From one of the lymphatic vessels above described, a growth prpjeclid
into the cavity of the vena cava, and a small tuft-like isolated growth of cartilage wis*
tached to the inner coat of the vein, near the termination of one of the renal veins. El-
cepting these, all the other veins examined appeared healthy in structure and cootenii^
MIXED CARTILAGINOUS TUMORS. 469
Multiplicity is safficiently marked in the cases of the hands and feet,
bat has been observed, though more rarely, in other parts ; as in a case
recorded by Mr. William Adams, and already referred to, as presenting
tomors at once in the scapula and parts of the humerus. The case of
Mr. Bickersteth (p. 446) was probably of the same kind.
Hie hereditary occurrence was observed in the case of a cartilaginous
tumor of the pelvis, of which I have already spoken, as examined by
Mr. Donald Dalrymple. The patient's father had a large ossified en-
chondroma of the radius, which was removed by Mr. Martineau.'*'
The conjunction of cartilaginous and medullary cancerous tumors
may, perhaps, be called frequent, especially in the testicle.
A man, 88 years old, was under Mr. Lawrence's care with an appa-
rent enlargement of one testicle, which he ascribed to a blow received
eighteen months previously. Three weeks after the blow he noticed an
enlargement, which regularly increased, and formed an oval mass about
four inches long. This, at its upper part, was moderately firm and
elastic ; but in the lower third it felt incompressibly hard. It was re-
moved, and proved to be a pale, soft, grayish, medullary cancer in the
testicle, having in its lower part a mass of cartilage, with scattered
points of bone, and some intercellular tissue. f The patient died a
fortnight after the operation ; and it was interesting to observe, as illus-
trating the contrast between the cartilaginous and the cancerous growths,
that he had soft medullary cancerous tumors in the situation of his lum-
bar lymphatic glands, but no cartilaginous tissue in or mingled with
them.
The lymphatics also were not afTected beyond the parts already described. In the lungs,
however, cartilage had formed in very large quantities, and existed imbedded in the
healthy pulmonary tissue, in cylindriform, or nearly spherical, lobed, and nodular pieces.
Id many of the lai^er branches of the pulmonary artery, small shrub-like growths of carti-
lage, like that in the vena cava, were attached to, without protruding through, the lining
membrane.
A case has also been recorded by M. Richet (Gaz. des Hdpitaux, AoClt 14, 1855) in
which a large cartilaginous tumor of the scapula was removed. The patient went on well
for aome time, but then died of an obscure pulmonary affection. At the examination af\er
death, a large number of tumors were found in the lungs, possessing the same structure as
the one removed from the scapula.
We must admit that in both the above cases a ^ generalization^' (to employ a term used
by some pathologists) of the cartilaginous tumors had taken place. But in them the evi-
dence seems conclusive that the materials of the tumors were carried, from the seat of
origioal formation of the growth, by the blood into the lungs, and served there as germs for
die development of secondary tumors. But this does not make them identical with malig-
nant tumors, in which the ** generalization*' is commonly effected by causes independent of
any such mechanical transference of germs.
* The specimens are in the Museum of the Norfolk and Norwich Hospital. In the
Edinburgh Monthly Journal, vol. xiii, p. 195, an abstract of the case is published by Dr.
Cobbold, who relates, in addition to the facts I had learnt from Mr. Thomas Crosse, that
ft brother of the man who had the tumor in the pelvis has mollities ossium, and that
''others of his kindred had been subjected to the debilitating influences of a perverted
nmrition.'*
f The specimens and drawings are in the Museum of St Bartholomew's.
460 MIXED CARTILAGINOUS TUMORS.
A specimen closely resembling this, and with a very similar historj,
is in the Mnsenm of the University of Cambridge. Another is in the
Museum of 6uy*s Hospital, of which it is said that the patient died
with return of the medullary disease. Miiller noticed the same com:
bination.* Virchowf has cited two cases, and described one, all illus-
trating the same singular fact. In the three specimens that I haye
seen of conjunction of cartilaginous and medullary growths in the
testicle, the cartilage appears as an isolated mass in the substance of
the medullary tumor, and is inclosed in a distinct capsule. There
are other cases, however, in which the two morbid substances, though
distinct, yet lie in so close contact that they are confused with one an-
other. Thus, in a tumor which, as already mentioned (p. 444), was
attached to the front of the lumbar vertebrae, and weighed thirteen
pounds, half was formed of soft flocculent medullary cancer, and half
of nodules of cartilage, some with soft, some with osseous centres.^ A
tumor removed from over a woman's parotid gland by Mr. Lloyd was
invested by a single capsule of connective tissue; but one-half wm
cartilaginous, and the other looked like medullary substance, and thej
were mingled, with no distinct boundary-line, at their contiguous
borders. § And, lastly, in a case of which preparations are in the Mu-
seum of St. Thomas's Hospital, Mr. Dodd removed a genuine and
apparently unmixed cartilaginous tumor from a man's ribs; but, in
three months, another tumor appeared in the same part, formed of
closely-mingled cartilage and medullary substance. This quickly proved
fatal.
I need hardly remark on the bearing which this last case may have
on the question of the recurrence of cartilaginous tumors, and on that
of the changes of character which may ensue in tumors generally, at
their successive occasions of recurrence. It gives to all these cases a
much higher interest than would attach to them if regarded only as
rarities and strange things.
But it is not with the malignant diseases alone that cartilage is found
in tumors. I have described it as combined with what appears like
glandular tissue in the tumors over the parotid, and I have seen bone
in similar combination in a tumor in the lip. Specimens are not rare
in which closely-grouped nodules and irregular masses of pure white
cartilage are imbedded in fibro-cystic tumors in the testicle. || In
* On Cancer.
f Verhandl. der phys.-med. Gesell8chaf\ in Wiirzburg, i, p. 134. Baring (Ueber dn
Markschwamm der Hoden, pi. ii.) has represented a similar specimen.
J Mus. Coll. Surg., 207 ; Mus. St. Bartholomew's, Ser. xxxv, No. 49.
§ Mus. Coll. Surg., 207 a ; Mus. St. Bartholomew's, Ser. xxxv, No. 45. The patient im
alive at least seven years after the removal of the tumor.
II Illustrative cases of this may be found in Mr. Curling's paper, " Observations on Cystic
Disease of the Testicle," Med.-Chir. Trans., vol. xxxvi, p. 449, and in a paper by Billroik,
Virchow's Archiv, viii, 1855.
MYELOID TUMORS. 461
speaking of the fibro-cellular tumors, I mentioned two in which carti-
lage was similarly mingled with their more essential constituent ; and
in the Museum of Gay's Hospital is a tumor removed from beneath the
gastrocnemius muscle, which consists of both connective and adipose
tissue, with abundant imbedded nodules of cartilage. And, lastly,
similar combinations appear to exist of cartilaginous growths with
those which M. Lebert named fibro-plastic, and which will be described
in the next lecture as myeloid tumors. Such is, I believe, the compo-
sition of three tumors in the Museum of St. Bartholomew's, of which
one surrounds the head of the tibia ;'*' another involves the bones of the
face, and extends into the cranium ;t and a third occupies and expands
the lower end of the fibula.| The compound structure of the last was
ascertained with the microscope, which easily detected the two mate-
rials irregularly mingled in every part of the tumor.
In all these facts concerning its combination with other morbidly pro-
duced structures, there must be something of much importance in rela-
tion to the physiology of cartilage ; but as yet, I believe, we cannot
comprehend it. Such combinations are not, I believe, imitated in the
cases of any other structures found in tumors ; even those that are thus
combined with cartilage do not, I think, combine with one another, if
we except the cases of intra-uterine morbid growths. As yet, however,
the interest that belongs to all these inquiries is scarcely more than the
interest of mystery, and of promise to future investigators. As yet,
we can think scarcely more than that, as innocent tumors, generally,
are remote imitations of the abnormal excesses of development which
occur in embryo-life, so it might be expected that, in some of them,
many of the tissues would be combined in disorder, which, orderly ar-
ranged, make up the foetus.
LECTURE XXVIL
PART I.
MYELOID TUMORS.
Thr Tumors for which I venture to propose the name of Myeloid
(/ic/Ciltti^?, marrow-like), were first distinguished as a separate kind by
M. Lebert.§ Before his discovery of their minute structure, they were
confounded with fibrous tumors, or included among the examples of
sarcoma, and especially of osteo-sarcoma. M. Lebert gave them the
* Series i, 41 ; and Mr. Stanley's Illustrations, pi. 15, fig. 3.
f Ser. XXXV, 47 ; and the same Illustr., pi. 13, fig. 4.
X Appendix to Pathol. Catal.
$ Physiologie Pathologique, ii, p. 120; and Abhandlungen, p. 123.
462 MTELOID TUMORS.
name of "fibro-plastic/* having regard to their containing corpuscles
like the elongated cells, or iibro- cells, which he has called by the same
name, and to which I have so often referred as occurring in the rudi-
mental fibro-cellular and fibrous tumors, and in developing lymph and
granulations. But the more characteristic constituents of these tumors,
and those which more certainly indicate their structural homology (t. e,
their likeness to natural parts) are peculiar many-nucleated corpuscles,
which have been recognized by Kolliker* and Robinf as constituents
of the marrow and diploe of bones, especially in the foetus and in early
life. It seems best, therefore, to name the tumors after this their nearest
affinity. On similar grounds, they must be regarded as having a nearer
relation to the cartilaginous than to the fibrous tumors ; for their essen-
tial structures, both the many-nucleated medulla-like corpuscles and
the elongated cells, are (like those of cartilaginous tumors) identical
with normal rudimental bone-textures. Moreover, as I have already
said (p. 461), portions of myeloid structure are sometimes mixed with
those of cartilaginous tumors, and they are sometimes developed into
naturally constructed cancellous and medullary bone. The structures
of this group of tumors are, indeed, essentially similar to those found in
granulations which grow from, and may be transformed into, bone ; and
to a section of such granulations some specimens bear, even to the un-
aided eye, no small resemblance.
The myeloid tumors may perhaps, like the cartilaginous, be found in
other situations than in connection with the bones ; but they are far
more frequent in or upon the bones than in any other tissue. I have
seen the myeloid structures in the mammary gland, and I think in the
neck, near the thyroid gland; and M. Lebert mentions many other
parts as occasionally containing tumors belonging to his " fibro-plastic"
group, especially the eyelids and conjunctivae, the subcutaneous tissue,
the cerebral membranes, and the uterus.J
As usually occurring in connection with the bones, a myeloid, like a
* Mikrosk. Anatomie, B. ii, pp. 364, 378.
f Compies Rendus. . . . de la Soci6te de Biologie, T. i, p. 150; T. ii, p. 8, and Memoirs,
p. 143.
t L. c. ; and in Virclmw and Reinhardt's Archiv, B iii, p. 4G3. But I think that in seferal
of these instances he has included in his account tumors containing only the elongated " fibro-
plastic" cells; whereas I have reckoned, as belonging to this myeloid group of tumors, none
but those Which, together with such cells, contained also the large many-nucleated corpuscles,
which alone are a peculiar constituent. A tumor containing elongated fibro-cells alone, I
should expect to be a rudimental fibro-cellular, or fibrous, or recurring fibroid tumor. They
may also appear as a chief constituent in tumors containing abundant inflammatory exuda-
tion. M. Lel>ert communicated an essay on fibro-plastic tumors to the Socifetfe de Chirurgie,
of which an abstract is published in the Archives Gfen. de Medecine, Jan., 1853. So far ii
I can judge from this abstract, it is very advisable to maintain the distinction which I have
proposed, between the myeloid tumors, which are composed of rudimental bone-tissues, and
those which (whether they be called fibro-plastic, or by any other name) consist of stnicturw
rudimental, of fibro-cellular or fibrous tissue. The anatomical distinction between the two
groups is determined by the presence or absence of the many-nucleated cells characteristic
of the myeloid tumors.
STBUOTURE OF MYELOID TUMORS. 468
fibrous, tumor may be either inclosed in a bone whose walls are ex-
panded round it, or, more rarely, it is closely set On the surface of a
bone, confused with its periosteum. The sketches in p. 433, of fibrous
tumors within and upon the lower jaw, might be repeated here for
myeloid tumors ; and the two kinds are about equally common in the
same positions, both within and upon the upper jaw. When inclosed
in bone, the myeloid tumors usually tend to the spherical or ovoid shape,
and are often well-defined, if not invested with distinct thin capsules ;
seated on bone, they are, as an epulis of this structure may exemplify,
much less defined, less regular in shape, and often deeply lobed. They
feel like uniformly compact masses, but are, in different instances,
variously consistent. The most characteristic examples are firm ; and
(if by the name we may imply such a character as that of the muscular
substance of a mammalian heart) they may be called ^^ fleshy." Others
are softer, in several gradations to the softness of size-gelatine, or that
of a section of granulations. Even the firmer are brittle, easily crushed
or broken ; they are not tough, nor very elastic, like the fibro-cellular
or fibrous tumors ; neither are they grumous or pulpy ; neither do they
show'a granular or fibrous structure on their cut or broken surfaces.
On section, the cut surfaces appear smooth, uniform, compact, shining,
succulent with a yellowish, not a creamy, fluid. A peculiar appear-
ance is commonly given to these tumors by the cut surface presenting
blotches of dark or livid crimson, or of a brownish or a brighter blood-
color, or of a pale pink, or of all these tints mingled, on the grayish-
white or greenish basis-color.* This is the character by which, I think,
they may best be recognized with the naked eye, though there are
diversities in the extent, and even in the existence, of the blotching.
The tumor may be all pale, or have only a few points of ruddy blotch-
ing, or the cut surface may be nearly all suffused, or even the whole
substance may have a dull Modena or crimson tinge, like the ruddy
color of a heart, or that of the parenchyma of a spleen. f
Many varieties of aspect may thus be observed in myeloid tumors ;
and, beyond these, they may be even so changed that the microscope
may be essential to their diagnosis. Often, they partially ossify ; well-
formed, cancellous bone being developed in them. Cysts, also, vary-
ing considerably both in number and size, and filled with bloody or
serous fluids, may be formed in them, occupying much of their volume,
or even almost excluding the solid texture. In the last case, the recog-
nition of the disease is very difficult. I lately amputated the leg of a
woman, 24 years old, for what I supposed to be a cancerous tumor
* Lebert saySf the greenish-yellow color that they may show depends on a peculiar sort
of fat, which he calls Xanthose (Abhandl. 127).
f I believe that many of what have been named spleen-like tumors of the jaws have been
of this kind. The color they present is not due only to blood in them ; more of it is appro-
priate to their texture, as that of the spleen is, or that of granulations ; and it may be quickly
and completely bleached with alcohol.
464 STRUCTURE OF HYBLOID TUMORS.
growing within the head of the tibia. She had had pain in this part
for eighteen months, and increasing swelling for ten months ; and it
was plain that the bone was expanded and wasted around some soft
growth within it. On section, after removal, the head of the tibia, in-
cluding its articular surface, appeared expanded into a round cyst or
sac, about 3^ inches in diameter, the walls of which were formed by
thin flexible bone and periosteum, and by the articular cartilages abore.
Within, there was little more than a few bands or columns of bone,
among a disorderly collection of cysts filled with blood, or blood-colored
serous fluids. The walls of most of the cyste were thin and pellucid;
those of some were thicker, soft, and brownish-yellow, like the substance
of some medullary cancers ; a likeness to which was yet more marked
in a small solid portion of tumor, whicb, though very firm, and looking
fibrous, was pure white and brain-like.
None who examined this disease with the naked eye alone felt any
doubt that it was an example of medullary cancer, with cysts abun-
dantly formed in it. But, on minuter investigation, none but the ele-
ments which I shall presently describe as characteristic of the myeloid
tumors could be found in it : these, copiously imbedded in a diml;^-grB-
nular substance, appeared to form the substance of the cyst-walls, and
of whatever solid material existed between them. The white brain-like
mass was, apparently, composed of similar elements in an advanced
fatty degeneration ; neither in it, nor in any other part, could I find •
semblance of cancer-cells.
I have not seen another specimen deviating so far from the nsutl
characters of myeloid tumors as this did ; but I think that, as in this,
so in any other variation of general aspect, the microscopic structurw
would suffice for diagnosis ; for there is no other morbid growth, m
far as I know, in which they are imitated. They consist essentially
of cells and other corpuscles, of which the following are the chief
forms ;
1. Cells of oval, lanceolate, or angular shapes, or elongated and at-
tenuated like fibro-cells or caudate-cells, having dimly dotted contents,
with single nuclei and nucleoli (Fig. 71).
Pig. 71.*
• Fig. 71. I
celli (Ubert).
BISTORT OF MYELOID TUMORS. 465
2. Free nuclei, such as may have escaped from the cells ; and, among
these, some that appear enlarged and elliptical, or variously angular,
or are elongated towards the same shapes as the lanceolate and cau-
date cells, and seem as if they were assuming the characters of cells.
8. The most peculiar form ; — large, round, oval or flask-shaped, or
irregular cells and cell-like masses, or thin disks, of clear or dimly-gra-
nular substance, measuring from joo^h to j|)\)o^^ of an inch in diameter,
and containing from two to ten or more oval, clear, and nucleolated
nuclei (Fig. 71 : see also Fig. 78).
Corpuscles such as these, irregularly and in diverse proportions im-
bedded in a dimly-granular substance, make up the mass of a myeloid
tumor. They may be mingled with molecular fatty matter ; or, the
mass they compose may be traversed with filaments, or with bundles of
connective tissue and bloodvessels ; but their essential features (and
especially those of the many -nucleated corpuscles) are rarely obscured.
Respecting the general history of the myeloid tumors, the cases
hitherto minutely observed are too few and too various to justify many
general conclusions. Kot that the disease is a rare one: for there can
be no doubt that many cases recorded as examples of epulis, of fibrous
tumors of the jaws, of osteo-sarcoma, and even of cancerous growths
about the bones, should be referred to this group. When these lectures
were delivered and first published, no cases but those by M. Lebert,
and those which I had myself been able to observe, were open to me
for comparison, but since that time the attention of surgeons and pa-
thologists having been directed to this form df tumor, many additional
cases have been recorded. From these, the most general facts I can
collect are, that the myeloid tumors usually occur singly ; that they
are most frequent in youth, and very rare after middle age ; that they
generally grow slowly and without pain ; and generally commence with-
out any known cause, such as injury or hereditary disposition. They
rarely, except in portions, become osseous ; they have no proneness to
ulcerate or protrude ; they seem to bear even considerable injury without
becoming exuberant ; they may (but I suppose they very rarely) shrink,
or cease to grow ; they are not apt to recur after complete removal,
although their recurrence has been in more than one case observed ;*
nor have they, in general, any features of malignanl disease, although
myeloid structures have occasionally been found mingled with the ordi-
nary structures of medullary cancer, f
* See the cases related in.the note, p. 449.
•f Cases by Mr. Cock, in Trans. Path. Soc., viii, 389, and at p. 346 of the sanne volume a
case is related by Mr. J. Hutchinson, in which the upper end of the shaf\ of the humerus
ind several enlarged infra-axillary glands were removed on account of a myeloid tumor of
the humerus. Thickening and fungous growths appeared a few weeks af\er in the operation
nround,and five months af\er the operation the patient died. The last formed growths dis-
sloaed well-marked cancerous structure, and several deposits of soA cancer were found in
the right lung.
466 HISTORY OF MTELOID TUMORS.
I may illustrate these general statements by abstracts of some of the
cases I have recorded, selecting for the purpose those which were, on
any ground, the more remarkable.*
A lad, 18 years old, was imder Mr. Stanley's care, fifteen years ago,
with a tumor occupying the interior of the symphysis, and immediately
adjacent parts of his lower jaw-bone. It had been observed gradually
increasing for eight months without pain, and in its growth had disparted
the walls of the jaw, hollowing out a cavity for itself, and projecting
into the mouth through one of the alveoli. Mr. Stanley removed the
portion of the jaw, from the first left true molar to the first right pre-
molar tooth. The tumor presented the greenish and grayish basis,
blotched with crimson and various brownish tints, and the characters
of firmness, succulency, and microscopic texture, which I have described
as most distinctive of the myeloid tumors. It was the specimen from
which some of the microscopic sketches were made, and might be con«
sidered typical. This patient is still in good health, with no appearance
of return of the disease.
Mr. Lawrence had under his care a woman, 21 years old, with a tu-
mor in the alveolar part of the front of the upper jaw. This was of
about twelve months' duration, and had sometimes been very painful
It was seated in the cancellous tissue between the walls of the alveolar
and adjacent portion of the upper jaw, projecting slightly into both the
mouth and the cavity of the nose, and raising their mucous membranes
after passing through the wasted bone. After cutting away the front
wall of the jaw, the tumor was cleared out from all the cavity in which
it lay imbedded. It was in all microscopic characters like that last
mentioned, and resembled it in general features, except in that it had
in every part the dark ruddy color of a strong heart. There was no
reappearance of the disease for two years after the performance of the
operation, such as would have occurred in the case of a malignant tu-
mor, if an attempt had been made to remove it without the bone in
which it was growing. The patient was then lost sight of, so that no
further history can be given.
A woman, 22 years old, was under Mr. Lawrence's care, in March,
1851, from the alveolar part of whose right jaw, growths which were
regarded as examples of epulis, had been four times removed in the
previous thirteen months. In the fourth operation, in August, 1850,
the growth was found to extend through the socket of the first molar
tooth into the antrum, or into a cavity in the jaw. It was wholly re-
moved (as it was thought), and the wounds healed soundly ; but nine
weeks afterwards a fresh growth appeared, that seemed to involve or
arise from nearly the whole front surface of the right upper jaw-bone :
it was firm, tense, and elastic, but not painful, projecting far on the face,
as well as into the nostril, and into the cavity of the mouth at both the
^ The specimens obtained from all the following cases are in the Museum of St. Bartbofc^
mew's.
HISTORY OF MTELOID TUMORS. 467
gam and the hard palate. This swell ing, under various treatment,
rapidly inoreased ; fl[nd in December, 1850, a similar swelling appeared
at the left canine fossa, and grew at the same rate with that of earlier
origin. Of course the coexistence of two such swellings led to the fear,
and in some minds to the conviction, that the disease was cancerous ;
and the more, because, at nearly the same time with the second of these,
two soft tumors had appeared on the parietal bones. Still, the patient's
general health was but little impaired; and when the mucous mem-
brane of the hard palate ulcerated over the most prominent parts of the
tumors, neither of them protruded, or bled, or grew more rapidly.
In April, 1851, the growth of the tumors appeared to be very much
retarded, and for the next month was hardly perceptible ; and the pa-
tient being very urgent that something should be done to diminish the
horrible deformity of her face, Mr. Lawrence, in May, cut away the
greater part of the front and of the palatine and lower nasal parts of
the right upper jaw, and removed from the antrum all that appeared
morbid, including, doubtless, nearly every portion of the tumor.
The excised portion of the jaw-bone was involved and imbedded in a
large, irregularly spherical tumor, composed of a close- textured, shining,
soft, and brittle substance, of dark, grayish hue, su^used and blotched
with various shades of pink and deep crimson. It was not lobed, but
included portions of cancellous bone, apparently new-formed, and was
very closely adherent to all the surrounding parts. To the microscope
it exhibited all the characters that I have described above ; and the
many-nucleated corpuscles were remarkably well defined and full.
They composed nine-tenths of the mass, and were arranged like clus-
tered cells. The patient perfectly recovered from the efiects of the ope-
ration ; and, to every one's surprise, the tumor on the left upper jaw,
which had been in all respects like that removed from the right side,
gradually disappeared. It underwent no apparent change of texture,
but simply subsided. The swellings on the parietal bones, also, the
nature of which was not ascertained, cleared away ; and when the pa-
tient was last seen, a few months ago, she appeared completely well,
and no swelling could be observed.
No case could better show than this did the conformity of the mye-
loid tumors with the general characters of innocent, growths : on the
other hand, the following might well have been regarded as a malignant
disease, if its structure and limitation to a single part had not been con-
sidered.
A farmer's boy, 15 years old, was under Mr. Stanley's care, in the
winter of 1851, with a large tumor covering the upper part of his head,
rising to a height of from one to two inches above the skull, extending
nearly from ear to ear, and from the occipital spine to the coronal su-
ture. This had been in progress of constant growth for three years,
and was believed to have originated in the effects of repeated blows on
the head. The head now measured 21 inches in circumference, and 16|
inches over its transverse arch. Just before his admission he bad be-
come blind in one eye, and nearly so in the other ; his gait was un-
steady : he had severe pains in and about the forehead, but bis intellect
was not affected, and ho appeared in good general health. The scalp
over the tumor was exceedingly tense, and, at the most prominent pari,
rather deeply ulcerated. The temporal and oecipital arteries were very
large and tortuous : the corresponding veins felt like large sinuses.
In the last two months of his life, while in the hospital, hJa hlindneaa
became complete; he lost nearly all power of hearing, and suffered se-
vere paroxysms of headache. A. large portion of the scalp and of llie
subjacent tumor sloughed, leaving a great suppurating cavity in the
slill growing tumor. At length, two days before death, convulsions
ensued, which were followed by coma ; and in this he died.
The tumor covered all the surface of the skull in the extent above
mentioned, rising gradually from its circumference to a height of two
inches, at and about its central parts. A similar growth of somewlial
less dimensions existed within the corresponding parts of the interior
of the skull, including the dura mater and longitudinal sinus, and deeply
impressed the cerebrum. And, again, material similar to that forming
these growths was infiltrated in and expanded the included parts of tiie
bones of the vault of the skull. From both surfaces of these bone*
osseous spicula and thin tamellfe extended into the bases of other cor-
responding parts of the tumor. The adjacent sketch (Fig. 72), from
the preparation in the Museum of St. Bartholomew's, shows the rela-
tions of this singular growth to the skull and brain, as seen in a trans-
verse section.
The extra-cranial portion of the tumor had a nearly uniform denw
and elastic texture, of dull yellow color, mingled with white. Its cut
Pig. 72.
HISTORY OF MTELOID TUMORS.
469
volving the pericranium, and partially exposed by ulceration of the
Bcalp. The intra-cranial portion was soft, easily crushed and broken
into pulp, purple, streaked with pale gray and pink tints. It looked
obscurely fibrous, and was intersected by shining bands derived from
the dura mater and falx involved in it. To the naked eye it was like
a softer medullary tumor, and was closely connected with the impressed
surface of the brain, in the substance of which, just beneath it, was a
large abscess.
Difierent, however, as the two parts of the tumor appeared, there
was no corresponding difference in their microscopic elements ; these
were essentially the same in both parts ; and though the tumor was so
like cancer in its general aspect, yet its minute structures were not
cancerous. They were chiefly as follows : (1) Regular, oval, and well-
defined cells, about ^J^th of an inch in diameter, containing dimly-granu-
lar or dotted substance, in which many oval nucleolated nuclei were
imbedded (Fig. 78 a). They corresponded exactly with the corpuscles
characteristic of the myeloid tumors ; but they had more distinct cell-
walls than I have seen in any other case, and some had even double
contours, as if with very thick cell-walls. (2) Irregular masses or
fragments, of various sizes and shapes, having the same apparent sub-
stance as the contents of the cells, and containing similar numerous
imbedded nuclei, but no defined cell-walls (Fig. 73 b). In these also,
the identity with the constituents of myeloid tumors was evident. (3)
More abundant than either of these forms were bodies like the many-
nucleated cells, but having on their walls, as it were wrapped over
them, one or more elongated caudate nucleated cells (c). They seemed
Fig. 73.*
■^m-
^v^^r
c
to be formed like the peculiar corpuscles in epithelial cancers, in which
one finds cells or clusters of nuclei invested with layers of epithelial
scales concentrically wrapped round them. Their borders presented
two or three concentric lines, as if laminated ; between these were one
or more nuclei ; and often the innermost of the lines was bayed inwards
towards the cell-cavity, leaving a space in which a neucleus was lodged.
Sometimes, from the circumference of such bodies, one could find
curved nucleated elongated cells dislodged (d). In most instances these
* Fig. 73. MiciOBCopic elements of the myeloid tumor of the skull, described in the
text Bfagnifiad 350 times.
470 HISTORY OF MYELOID TUMORS.
laminated cells were filled with the dimly-granular substance and the
many nuclei ; but in some there were clear spaces, that seemed to con-
tain only pellucid liquid. The elongated cells that could be sometimes
detached from these laminated cells agreed, in general characters, with
the remaining principal constituent of the growth ; namely, (4) narrow,
long, caudate and fusiform cells with outswelling nuclei, like those of
developing granulations, and such as I have described as constant ele*
ments of the myeloid tumors.
All the minute structures just described were found closely compacted,
and making up with free nuclei and granular matter the mass of both
portions of the tumor ; and the only apparent difference was, that in the
intra^cranial portion, they appeared more generally to contain granules,
and to be mixed with granule-cells and granule-masses, as if this part
of the tumor were more degenerate than the other.
I fear that even so abbreviated a record of this case as I have ven-
tured to print may seem very tedious ; but it is not for its own rarity
alone that the case is important. It would be difficult to find a tumor
more imitative of cancer than this was in its mode of growth, its infil-
tration of various tissues, its involving of important parts, its apparent
dissimilarity from any natural structures. And yet it certainly was not
cancer; the microscopic elements were like those of natural parts: not
a lymphatic or any other organ was affected by a similar disease, and
death seemed to be due solely to the local effects of the growth.*
But while these, and many other cases, may be enough to prove that
the myeloid tumors are generally of innocent nature, yet I suspect cases
may be found in which, with the same apparent structures, a malignant
course is run. Of such suspicious cases the two following are examples:
A woman, 50 years old, was under Mr. Stanley's care, in 1847, with
an irregular, roundish, heavy tumor, between two and three inches in
diameter, in her left breast. It projected in the breast, and the skin
over it was red and tense, and at one part seemed to point, as if with
suppuration. Some axillary glands were enlarged, but not hardened.
This tumor had existed about nine months, had been the seat of
occasional pain, and was increasing. It was considered to be hard
cancer ; but, on the removal of the breast, was found to be a distinct
growth, completely separable from the mammary gland, which WM
pressed aside by it. Its character was obscured by suppuration in
many points of its substance ; yet, after a careful examination of it in
the recent state, and a repeated examination of the notes and sketches
that I made of its structure, I can only conclude that it was a myeloid
tumor suppurated, or, possibly, mingled with cancer.
Eighteen months after the removal of her breast, this patient returned
* A collection of cases of myeloid tumors, several of which occurred in the practice of
Sir B. Brodie, by Mr. H. Gray, may be found in Med.-Chir. Trans., vol. xxxix, 1856; aod in
the Trans. P&ih. Soc., vol. vii, are other cases related by Dr. Bristowe, Mr. C. Hawkins, tod
Mr. B. Childs.
HIBTORT OF MTBLOID TUMORS. 471
to the hospital, with a large ulcerated tumor in the lower part of her
left axilla, which had begun to form as a distinct tumor six months after
the operation. This was like a large flat ulcerated cancer : it often
bled freely. Her general health was deeply afiected by it, and she
died in two or three months after her readmission.
The malignant character manifested in this case was yet more de-
cidedly marked in another. A man, 53 years old, of healthy appear-
ance, was under Mr Lawrence's care, with an oval tumor, extending,
under the mastoid muscle, from the angle of the jaw to the clavicle.
Bloody serum oozed from it through three small apertures in the in-
teguments. The anterior part of the tumor felt as if containing
fluid; the posterior part felt solid, firm, and elastic. He had observed
this tumor for ten months, having found one morning, when he awoke,
a lump nearly as large as an egg, which regularly increased. In two
months it had become very large : it was punctured, and about one-third
of a pint of reddish serum was discharged from it. In the succeeding
eight months it was tapped thirty-four times more, about the same quan-
tity of similar fluid being each time evacuated. It was also six times
injected with tincture of iodine, twice traversed with setons, and in
various other ways severely treated. The only general result was, that
it increased, and seemed to become, in proportion, more solid. When
admitted under Mr. Lawrence, all the parts over the tumor were ex-
tremely tense and painful, and cerebral disturbance appeared to be
produced by its pressure on the great bloodvessels of the neck. It was
freely cut into, and the surface which was exposed presented well-
marked characters of the myeloid tumors such as I have described.
Some small portions that were removed enabled me to confirm this with
the microscope. The elongated, and the many-nucleated cells, were,
to all appearance, decisive. The incision of the tumor produced tem-
porary relief; but the tumor continued to grow, and death occurred
nearly twelve months from its commencement. In examination after
death, the solid portion of the tumor formed five-sixths of its bulk, the
rest consisting of a suppurating cavity. The microscopic characters of
the solid part were exactly like those of the portions removed during
life, though the substance appeared firmer and whiter than before, and
yielded, when scraped, a creamy fluid. Four small masses of similar
substance were found in the lungs ; and a similar material was difi'used
in one cervical gland.*
Now in both these cases, and especially in the last, the whole history
of which seems full of anomalies, there were certainly such features of
♦ In the Trans. Path. Soc., vol. ix, jx 367, a case is communicated by Mr. Henry, in which
a myeloid tamor, the size of an orange, was removed by amputation through the shoulder-
joinL Some six weeks aAerwards a rapidly-growing recurrent tumor appeared. The
patient died three months aAer the operation. The recurrent tumor contained the charac-
teristic myeloid bodies. Secondary myeloid deposits were found in both lungs. See also a
case by Dr. Wilks, in vol. x, p. 244, which is again referred to in a note on p. 577.
472 OSSEOUS TUMORS.
dissimilarity from the usual general characters of the myeloid tumors,
that, although the microscopic characters appeared identical, yet they
are not enough to prove even the occasional malignancy of the disease:
they are enough to make us cautious ; enough to induce us to study
this disease very carefully, as one of those that may, in different con-
ditions, or in different persons, pursue very different couAes ; appearing
in some as an innocent, in others as a malignant disease. The use of
such terms as *^ semi-malignant,'' ''less malignant than cancer," and
the like, in relation to growths of this kind, involves subjects of singu-
lar interest in pathology, as well as in practical surgery. But I will
not now dwell on them. The whole subject may be more appropriately
discussed in the lectures on malignant tumors.
LECTURE XXVII.
PART II.
OSSEOUS TUMORS.
Much of the general pathology of osseous tumors has been considered
in the last two lectures, which have treated of the tumors composed of
rudimental bone-textures. Ossification may ensue in either a cartila-
ginous or a myeloid tumor. In the latter it is rarely, if ever, more
than partial, in the former it may be complete ; and the cartilaginous
may be transformed into an osseous tumor. The name of osseous tu-
mor is, however, not usually applied to those in which ossification is in
progress. It is reserved for such as are formed wholly of bone : and
of these I shall now chiefly speak.
Osseous tumors, even more generally than cartilaginous, are con-
nected with the bones, with which, moreover, though they may have
the other characters of tumors, they are almost always continuous, after
the manner of outgrowths. They are, however, occasionally found in
soft parts, as distinct and discontinuous tumors, invested with capsules
of connective tissue. Thus in the College Museum (No. 203) is a small,
completely osseous, tumor, formed of soft cancellous tissue with me-
dulla, which lies over the dorsal surface of the trapezial and scaphoid
bones, completely isolated from them and all the adjacent bones. In
the Museum of St. George's Hospital is a tumor formed of compact
bony tissue, which lay over the palmar aspect of the first metacarpal
bone, loosely imbedded in the areolar tissue, and easily separated from
the flexor tendons of the finger.* It had been growing five years in a
* An account of it is reported in the Medical Times, Aug. 3, 1850.
OSSEOUS TUMORS. 473
middle-aged woman. So, but rarely and imperfectly, the cartilaginous
tumors over the parotid gland are ossified ;* and those in the lungsf
and testicle.
At present, these isolated osseous tumors are interesting for little
more than their rarity. It is to those connected with bones that I must
now particulaiV^ address myself.
I have already said that these have the character of continuous
growths ; that they are like outgrowths rather than tumors. And it is
not easy to draw any line of distinction between what deserve to be
considered as tumors, and such accumulations of bone as may ensue in
consequence of superficial inflammation, or other disease, of the bone
or periosteum. The exostoses and hyperostoses of nosology are not to
be severally defined without artifice ; but, in general, we may take this
as a convenient, and perhaps a just, method of dividing them : namely,
that those may be reckoned as osseous tumors, or outgrowths of the
nature of tumors, whose base of attachment to the original bone is de-
fined, and grows, if at all, at a less rate than their outstanding mass.l
Those which are not of the nature of tumors are generally not only ill-
defined, but widely spread at their bases of attachment ; and the addi-
tions made to them increase their bases rather than their heights or
their whole masses.
Of osseous tumors, thus roughly defined, two chief kinds may be
observed ; namely, the cancellous, and the compact or ivory-like, which,
speaking generally, may be said to resemble respectively the medullary
tissue, and the walls or compact substance, of healthy bone. In both
alike, the bone is usually true and good bone. By my own observations
of it I know no more than this ; but Mr. Quekett, who has submitted
to microscopic examination portions of all the osseous tumors in the
College Museum, confirms the general statement in all particulars. In
different specimens there may be varieties in the proportion and ar-
rangement of bloodvessels, and in the size and development of the
bone-corpuscles or lacunae and their canals ; but the proper characters
of the bone of the species in which the tumor occurs are not far de-
parted from.
I believe the homology of the osseous tumors is, in chemical quali-
ties, as perfect as it is in structure ; and that, as with the natural
bones, so with these, we may not ascribe differences of hardness or den-
sity to the different proportions of the organic, and of the saline and
earthy components : but to the different manner in which the similar
material that they compose is, in different specimens, compacted. Their
varieties of hardness depend on mechanical rather than on chemical
differences.
Of the general methods of ossification of cartilaginous tumors I
* Mu8. Coll. Sarg., No. 204. f Museum of St Thomas's Hospital.
} Mr. Stanley particularly remarks this in relation to operations for removal of exostoses
(On Diiease^ of the Bones, p. 150).
31
474 OSSEOUS TUMORS.
spoke in my last lecture, and then noticed that in nearly all cases when
the ossification of the tumors is completed, they consist of a very thin
layer or wall of compact tissue, covering in a mass of cancellous and
medullary substance : and thus they are composed, whether the carti-
lage growth began within or upon the bone. It is • probable that, in
some instances, the hardest osseous tumors may be also formed by
transformation of cartilage into bone. Thus, an exceedingly hard,
ivory-like tumor at the angle of the lower jaw, in the Museum of the
College,'*' has so exactly the nodular and irregular spheroidal shape be-
longing to cartilaginous tumors, and to the rare cancellous bony tumors
in the same part, that we can scarcely doubt it had a primordial carti-
laginous condition. So, too, Professor Goodsir tells me, there is in the
Museum of the University of Edinburgh a tumor of the humerus (573)
removed by Mr. Syme, which is in its interior in part hard and com-
pact like ivory, whilst its surface is nodular and irregularly spheroidal,
and covered by a layer of cartilage.f In the Museum of Guy's Hos-
pital there is a somewhat similar specimen ; in which, however, the hard-
ness of the bone may be due to inflammatory induration of an ordinary
cancellous osseous growth.
* No. 1035; it may be compared with a cancellous tumor of the same form, io the Mu-
seum at St. George's Hospital, removed by Mr. Tatum.
t In a paper on pedunculated exostosis of the long bones, in the £d. Med. Jotim., Jan.,
1854, Mr. Syme records the removal of a similar exostosis from the neck of the humerus;
and at p. 7 of the same number of the Journal, an account of the structure of the tumor if
given by Mr. Lister. The surface of this tumor was irregularly nodulated, and in part
covered by cartilage. Beneath the cartilaginous-covered prominences there was a consider-
able thickness of a peculiar white compact substance, too gritty and friable for bone, which
proved to be calcified cartilage, and as a general rule this calcified cartilage was present io
the greatest amount where the cartilaginous covering was the thickest. In the more circum-
ferential parts of the tumor, where no cartilage existed, loose cancellous tissue extended
close to the surface, which was formed by a thin layer of compact tissue. The deeper sur-
face of the calcified cartilage presented many excavations, into which processes of medul-
lary substance and spicula of cancellous bone extended. The conclusion which Mr. Lister
draws from the examination is, that the exostosis grew as cartilage, and that in its conve^
sion into cancellated bone, the stage of calcification of cartilage occupied a very proroineDt
position.
Corresponding closely with the above, in their mode of growth at least, appear to be those
cases described by Virchow (Entwick. des Sohadelgrnnd : Berlin, 1857, p. 51, e. s.), in
which small exostoses projected from the upper surface of the os basilare into the cavity of
the skull. They were limited in size, and grew from the clivus, at the synostosis, between
the occipital and sphenoidal portions of the basilar process. They were evidently growths
from the cartilage, which originally connects these bones together, and ossification had taken
place in them, just as in the normal bones. In some cases a thin layer of cartilage still re-
mained on the surface of the exostosis. Virchow has found in some of these cases, small
gelatinous tumors of the size of a pea or cherry, connected to the exostosis by means of a
pedicle, projecting through the dura mater, and resting against the anterior margin of the
pons varolii, close to the place of division of the basilar artery. On microscopic examina*
tion, they were found to consist partly of bladder-like cells, similar to those which he had
already described in cancer, as Physaliphores (Archiv. iii, p. 197), and partly of an inter-
mediate substance, like the mucous tissue of the vitreous body, which gradually passed into
the large-celled cartilage covering the surface of the exostosis. Virchow has termed this
form of mucous tumor, ecchondrosis prolifera. Additional cases have been recorded bf
Luschka (Virchow 's Archiv. vol. xi, 1857) and Zenker (lb., vol. xii, 1857).
OSSEOUS TUMORS. 475
These, however, are probahly exceptions to the general rule concern-
ing the compact or ivory exostoses ; for, for the majority of these, Ro-
kitansky says tmly that no preparatory cartilage is formed. As, in
the natural ossification of the skull, the bone is formed, not in a matrix
of cartilage, but in fibrous tissue, layers of which are successively ossi-
fied, so probably are the hard bony tumors of the skull formed.
The general characters of the cancellous bony tumors are so nearly
described in the account of the cartilaginous tumors from which they
commonly originate, that I need only briefly refer to them. They
usually affect a round shape, with projecting lobes or nodules, which
answer to those of the conglomerate cartilaginous tumors, and are often
pointed or angular. They may, however, be very smooth on their sur-
face, whether they have grown within bones, whose extended walls form
now their outer layer, or without them on the periosteum. When com-
pletely ossified, their respective tissues, compact and medullary, are
usually continuous with those of the bone on which they are planted ;
and the later periods of growth seem attended with such mutual adapta-
tion as may tend towards making one continuous, though deformed, mass
of the old and the new bone.
The singularities of position in which the osseous tumors may be
found, and the important hindrances that may result from their inter-
ference with adjacent parts, I need not fully detail; they are amply
enumerated by Mr. Stanley. But it may not, perhaps, be uninterest-
ing to say a few words respecting those osseous tumors which not unfre-
quently grow at the attachment of tendons, especially at the lower end
of the femur, a little above the inner condyle, close to the insertion of
the adductor magnus.'*' These tumors are peculiarly apt to acquire a
narrow pedunculated base of attachment. In these cases one usually
finds a layer of cartilage incrusting some cancellous and medullary bone,
and the bone as a narrow pedicle extends into continuity with the wall
on the cancellous tissue of the subjacent shaft.f Such tumors have then
the characters of polypoid outgrowths from the bone, and may be treated
accordingly, for, when cut or broken off, their stems will not grow.
Indeed, that stem may chance to be unwittingly broken ; as in a tumor
removed by Mr. Lawrence.J It had grown on the inner and lower
part of the femur, and, when fairly exposed, was easily detached with-
out further cutting: the narrowest part of its stem rested in a slight
depression in the femur, but had no connection by tissue with it. It
seemed as if the narrow pedicle of a tumor, two inches in diameter, had
been by accident broken off, and the friction of the broken surfaces had
smoothed and fitted them together.
♦ Mr. Syme (op. cit. p. 5) records a case in which he removed one of these peduncu-
lated exostoses from the outer side of the thigh bone.
f A Tery illustrative figure of this pedunculated form of osseous tumor is given in Druitt's
Surgery, p. 214, 5th ed.
{ Mui. St Bartholomew's, Ser. i, 183.
476 IVORT-LIKB OSSEOUS TUMORS.
Of their rates of growth little is known ; but I believe that when a
cartilaginous tumor is completely ossified, the growth of the bony tumor
is extremely slow. However, osseous tumors may be found of an enor-
mous size. The largest that I know is in the Museum of the College.*
It nearly surrounds the upper two-thirds of a tibia, in an irregularly
oval mass, with a nodulated surface, almost entirely covered in by a
thin layer of compact tissue, and cancellous in all its interior. It
measures exactly a yard in circumference, and the limb, which was am-
putated by Mr. Gay, a former surgeon of St. Bartholomew's Hospital,
weighed forty-two pounds.
Another tumor of large size is in the Museum of the same Hospital. f
A great nodulated mass of bone is attached to the ischium and pubes,
and formed part of a tumor of which the rest was nodulated cartilage.
The compact, hard, or ivory -like bony tumors occur, especially, about
the bones of the head, and present several diversities of form. Some
are uniform and simple ; others variously lobed, or nodular. The simple
tumors are commonly attached to the skull by narrowed bases, over
which their chief masses are prominent on one side, or all round. A
good specimen of this kind is in the Museum of St. Bartholomew's Hos-
pital,^ which shows, besides, that these tumors may consist of an exte-
rior hard, and interior cancellous, tissue, respectively resembling and
continuous with the outer table and the diploe of the skull. Some of
these hard tumors have the shape of biconvex lenses, resting with one
convex surface on the skull, or like a nut bisected, the flat surface being
in contact with the skull ; i,nd of such as these more than one may be
found on the same skull. §
A disease much more formidable than these exists in the nodulated.^
and larger hard osseous tumors connected with the bones of the skull
These are not like outgrowths from the outer table and diploe ; foi^
they often, or I believe usually, grow first between the tables of th^m
skull, or in the cavities of the frontal or other sinuses. Increasing ii
these parts, they may tend in every direction, penetrating the tables
the skull, and forming large masses, projecting as much into the interioi"
of the skull as on its exterior.
The most frequent seat of such tumors is in the frontal bone, espe-
cially about its superciliary and orbital parts ; and they are horrible
by their pressure into the cavities of both the cranium and the orbl^
compressing the brain, and protruding one or both eyes.
The characters of the disease, so far as the growth is concerned, are
well shown in a huge mass which grew from the forehead of an ox,
♦ No. 3220. It is engraved in Cheselden's Osteographea, Tab. 53, f. 1, 2, 3. A painting
of it is in the St Bartholomew's Museum.
t Series 1 A, No. 133; and Series 1, No. 118.
X Series 1, 71. Series 1 a, 124, in the same Museum, and No. 3215 in the Museum of the
College, are nearly similar specimens.
i Mus. Coll. Surg., 793. See also Miller's Principles of Surgery, p. 447, ed. 1853.
IVOBT-LIKB OSSEOUS TUMORS.
477
originftling apparently in the frontal sinaaes.* It is like & great sphe-
roidal mass of irory, measuring 8J inches in diameter, and weighing
upwards of sixteen ponnds. Its outer surface, though knobbed and
ridged, is yet compact, like an elephant's tusk ; and, in similar likeness,
its section shows at one part a thin investing layer, like the bone cover-
ing the ivory. It is nearly all solid, hard, close-textured, and heavy ;
only a few irregular cavities, and one with smooth walls, appear in its
interior, and you may trace the orifices of many canals for bloodvesBels.
Mr. Qnekett found that this tumor had a higher specific gravity than any
bone, except that which is found in what are called the porcellaneous
deposits, or transformations, in the heads of bones afiected with chronic
rheumatism. But it has in every part the structure of true bone.
Jost like this, in the general characters of their tissue, are the hard
bony tumors from the human frontal bone. In one, an Hunterian
specimen,t such a tumor, 2^ inches in diameter, deeply lobed and
knotted, fills the frontal sinuses and the upper part of the left orbit,
encroaches into the right orbit, and projects for nearly an inch on both
the surfaces of the skull. It appears to have originated in the ethmoidal
or frontal cells, and, in its growth, to have displaced and destroyed by
pressure the adjacent parts of the tables of the skull and the nail of
the orbit. It is, for the most part, as hard as ivory, but in its central
and posterior portion is composed of very close cancellous tissue.
A specimen, far surpassing this in size, but resembling it in all it«
general characters and relations, is in the Museum of the University of
Cambridge, and is represented in Fig. 74. It is the largest and best
specimen of the kind that I have seen, and its osseous structure is di»-
tinct ; only as Professor
Clark has informed me, ^'8- " t
it is irregular: in the
hardest parts there are
neither Haversian ca-
nals nor lacunie ; in the
less hard parts, the
oanaU are very large,
and the lacuose are not
uTsnged in circles
ftTOtmd them ; and
everywhere the lacunte
are of irregular or dis-
torted forms.
A smaller specimen
ii in the Museum of St.
• Hdi-CoII. Suig., 3210.
t Mu>. CoU. Surg., 7S5. Il IB engraved in BRitlie'i Morbid Anatom;, Fa«c. x, pi. 1, i
3l and in Home, PbiloKiph. Trana., vol. liizii, p. 239.
{ Fig. 74. Hard bony tumor of ibe akull : rroni Ihe Cainbridge University Muieum.
478 OSSEOUS OVERGROWTHS.
Bartholomew's Hospital. A girl, 20 years old, was admitted with pro-
trusion of the left eyeball, which appeared due to an osseous growth pro-
jecting at the anterior, upper, and inner part of the orbit. None but the
anterior boundaries of this growth could be discerned. It had been ob-
served protruding the eye for three years, and had regularly increased ;
it was still increasing, and produced severe pain in the eyeball, and
about the side of the head and face. It seemed, therefore, necessary to
attempt the removal of the tumor, or at least to remove some part of it,
with the hope that the disturbance of its growth might lead to its necrosis
and separation. A portion of it was with great difiSculty sawn oflF; but
the patient died with suppuration in the membranes of the anterior part
of the cerebrum.
Now all these cases, corroborated as they are by others upon record,
prove the general character and relations of these tumors. Their
nodular form, and uniform hard, ivory-like texture ; their growth in the
diploe or sinuses, as isolated or narrowly attached masses ; their ten-
dency to extend in all directions ; their raising and penetrating the
bones of the skull, and growing into the cavities of the skull and orbit;
all show the exceeding diflSculty and peril of operations on them. The
simpler kinds, that only grow outwards, may indeed be cut oflF with
advantage, though seldom without great difficulty ; and, often, the
attempt to remove them has been made in vain ; but these larger and
nodular tumors about the brow can very rarely be either cut off or
extirpated.*
The extirpation, hqi^ever, which may be impossible for art, is some-
times effected by disease : these tumors are occasionally removed by
sloughing. Such an event happened in a case related by Mr. Hilton;!
and the great ivory-like mass, clean sloughed away, is in the Museum
at Guy's. So, too, in a case by Mr. Lucas, a bony tumor at the edge
of the orbit, after growing eight months, was exposed by an incision
through the upper eyelid. The wound did not heal ; the tumor con-
tinued to grow; and, twelve months afterwards, it became "carious,"
and was detached. The course of treatment which these cases suggest
has been, I believe, the only one worth imitation ; njvmely, exposure of
the tumor, and application, if need be, of escharotics to the surface of
the bone.
These hard osseous tumors arc very rarely found in connection with
any bone but those of the skull. In the College Museum, however, is
a well-marked specimen in the lower jaw ; a nodulated mass, nearly
three inches in diameter, invests the right angle of the jaw, and is, in
its whole substance, as hard and heavy as ivory. I have already, also,
referred to cases of similar hard tumors on the humerus : but they are
extremely rare.
* The histories of some specimens in the Museum of St. George's Hospital illustrate the*
statements very well. See, also, Mr. Hawkins's Lectures (Med. Gaz., vol. xxi).
f Guy's Hospital Reports, vol. i.
OSSEOUS TUMORS IN THE TOBS. 479
Osseous tumors of the lower jaw appear to be less rare in animals
inferior to man ; for the College Museum contains three specimens,'*'
taken respectively from a Virginia opossum, a cat, and a kangaroo,
and, which is more singular, one from a codfish. In this specimen,t
a disk-shaped mass of bone, two inches in diameter, extremely heavy
and compact, is attached to the inner surface of the superior maxillary
bone.
In the texture of these very hard bony tumors connected with the
bones of the skull and the lower jaw, we may observe an instance of
the general rule of likeness between tumors and the parts most near to
them ; for their bone is like no other natural bone so much as the in-
ternal table of the skull, or the petrous bone, or inferior maxilla.
The same likeness is observable in the osseous tumors that are fre-
qaent on the last phalanx of the great toe, which, alone, now remain
for me to speak of.|
No adequate explanation, I believe, can be offered for the occurrence
of these growths. They may be sometimes referred to injury ; yet the
effects of injury to the great toe are so inconstant, that we cannot re-
fer to injury, as other than an indirect cause of the growth of tumors,
so singularly constant as these are in all their characters, and so nearly
without exception limited to the one toe of all that are exposed to
injury. They grow almost always on the margin, and usually on the
inner margin, of the end of the last phalanx of the great toe ; in only
one specimen have I seen such a tumor springing from the middle of
the dorsal surface of the phalanx ; and, in only two, similar tumors
from the last phalanx of the little toe.§ Growing up from the margin,
they project under the edge of the nail, lifting it up, and thinning the
skin that covers them, till they present an excoriated surface at the
side of the nail. Their growth is usually very slow, and when they
have reached a diameter of from one-third to one-half of an inch, they
commonly cease to grow, and become completely osseous. They are
among the tumors whose independence is shown not only by abnormal
growing, but by the staying of their growth when they have attained a
certain natural stature.
I believe that they are not uniform in their method of development.
In some specimens, I have seen no cartilaginous basis ; the bone ap-
peared to form in fibrous tissue, as it were following, and at length
overtaking, the fibrous growth. In another, the outer part of the tumor
was formed of a thin layer of fibrous tissue, and between this and the
♦ Nos. 1035-7-8.
t No. 1039. A similar specimen is in the Museum of the Boston (U.S.) Medical Society.
I Mas. Coll. Surg., 787-8-9, 790.
j In the Anatomical Museum of the University of Edinburgh are several specimens of
ezostoflis of the last phalanx of the great toe. Although many of these grow upon the inner
margin, yet others spring from the dorsal surface, and project under the body of the nail.
Iq two specimens, the growth is connected to the inner margin of the base of the last
phalanx.
480 OSSEOUS GROWTHS IN THB UPPER JAW.
growing bone was a layer of cartilage, which had extemaUy the stellate
nuclei, and internally the nuclei of ordinary form, among which the
processes of bone were extending.
Whichever way the bone is formed, it is, like that of the phalanx
itself, cancellous but very hard, and with small spaces, and compara-
tively thick cancelli or laminsB bounding them. The outer layer, too,
ip rough and ill- defined, so that the growth looks like a branch from
the phalanx, and, like a branch, is apt to sprout again when cut away,
unless at least the end of the bone on which it grows be removed with it.
The account of osseous tumors would be very incomplete, if there
were not added to it some notice of those growths which are most like
them, though they may lie beyond the range of any reasonable or con*
venient definition of tumors. Among these are certain growths of the
bones of the face, tumor-like in their most prominent parts, and yet
unlike tumors in that their bases of connection with the bones are very
ill-defined, and that from their bases the morbid changes in which them-
selves originated extend outwards, on the same or even to other bones,
gradually subsiding. In no instances can it be plainer than it is in
these, that a nosological boundary of ^'Tumors" must be an arbi-
trary one.
Such growths as these are not very rare in the superior maxillary
bone. Its ascending process may become enlarged and prominent,
with an ill-defined hard swelling, very slowly increasing, and sometimes
stopping short of any considerable deformity. But a much more formi-
dable disease exists when a large portion of the bone, or the whole an-
trum, is involved ; especially, because this is apt to be associated with
diseases in the adjacent bones.
An extreme case is shown in a specimen in the College from the
Museum of Mr. Langstafi".* Two large masses of bone, of almost ex-
actly symmetrical form and arrangement, project from the upper jaws
and orbits, and have partially coalesced in the median line. They are
rounded, deeply lobed, and nodular; nearly as hard and heavy as ivory;
perforated with numerous apertures, apparently for bloodvessels. They
project more than three inches in front of the face, and an inch on each
side beyond the malar bones ; they fill both orbits, the nasal cavities,
and probably the antra, and they extend backwards to the pterygoid
plates. Part of the septum of the nose, and the alveolar border of the
jaw, are almost the only remaining indications of a face. The disease
appears to have begun in the superior maxillary bones, and thence to
have spread over the bones of the face : similar disease, in a less degree,
existing in the bones adjacent to the chief outgrowths.
The patient, who was sixty years old, believed the disease had been
eighteen years in progress, and ascribed it to repeated blows on the
* Mus. Coll. Surg., 3236, A.
OSSEOUS GROWTHS IN THE UPPER JAW. 481
face. He suffered much pain in the face, eyes, and head. His eyes
projected firom the orbits : the right, after suppuration and sloughing
of the cornea, shrivelled ; the left was accidentally burst by a blow.
During the last two years of his life he occasionally showed symptoms
of insanity, and at last he died with apoplexy of the cerebral membranes.
The disease very rarely attains so horrible a state as is here shown.
More commonly it is almost limited to the antrum. In this case it may
exist with little deformity. In the Museum of St. Bartholomew's Hos-
pital (i, 62), is a specimen in which both the antra appear nearly filled
by the thickening and ingrowing of their walls ; only small cavities
remain at their centres. The new bone is hard, heavy, and nearly
solid ; yet it is porous or finely cancellous, and is neither so compact
nor so smooth on its cut surface as that of the ^' ivory exostosis.'' The
same disease is manifest in a less degree upon the outer surfaces of the
maxillary bones, and on the septum and side- walls of the nose.
The disease has a manifest tendency to concentrate itself in the max-
illary bones ; so much so, that if a case be met with where only one of
these bones is diseased, it may be removed with a fair prospect that
the disease will not make progress in the adjacent parts. I believe,
indeed, that this has been done, with a satisfactory result, in a case
where already slight increase of some of the bones near the maxillary
was observable : and there was good reason to anticipate the same re-
sult in a case on which Mr. Stanley operated. The patient was a girl,
fifteen years old, in whom enlargement of the nasal process of the su-
perior maxillary bone had been observed for eight years, and was still
increasing. It had as yet produced no pain, and no deformity of the
cheek, the orbit, or the palate : but it was regularly increasing; and as
it could be certainly expected to increase even more in width of base
than in prominence (this being the common tendency of the disease), it
was thought right to remove the superior maxillary bone while yet the
disease was limited to it. The patient died, ten days after the opera-
tion, with erysipelas. The specimen displays exactly the same disease
as do those last described.
Now, it sometimes happens that growths like these spontaneously
perish, are separated with the ordinary phenomena of necrosis, and
thus are naturally cured. Such an event was observed in a case under
the care of Mr. Stanley.
A man, 87 years old, was admitted with a slight convex smooth pro-
minence of the nasal process of his right superior maxillary bone, which
he had observed increasing for two years, but which of late had not in-
creased or given him any inconvenience. Indeed, he came to the hos-
pital not for this, but for a swelling of the right gum and the mucous
membrane of the hard palate, through fistulous openings, in which one
could feel exposed dead bone. These had existed for a month. The
swelling of the nasal process was so characteristic of the disease I am
describing, as to suggest at once the existence of such a growth ; but
482 MULTIPLE OSSEOUS GROWTHS.
the suppuration and necrosis threw obscurity on the case ; and it was
only watched and treated according to such indications as arose, till
after four months, the whole of the mass of bone with which the antrum
fiad been filled up was separated and pulled away.
The appearance of the sequestrum, a nearly spherical mass of hard,
heavy, and finely cancellous bone, an inch or more in diameter, leaves
no doubt of the nature of the disease.* The great cavity which re-
mained, opening widely into both the mouth and the nose, gradually
contracted, or was filled up, and the man recovered perfectly.
A similar event, I imagine, happened in a man who exhibited himself
at most of the hospitals in London, twelve years ago, with a great cavity
where all his right upper jaw-bone and his turbinated bones had once
been, and through which one could see the movements of his pharynx
and palate. This he said had been left after the separation of a great
tumor of bone.
The growths of this kind seem to merge gradually into elevations of
cancellous porous bone, which may be found on various parts of the
bones of the skull, but of the exact pathology and relations of which
we have, I believe, no clear knowledge. Specimens of them ar^ in the
Museum of the College, and the Museum of St. Thomas's Hospital is
peculiarly rich in them. In some there are great thickenings of one
or both tables of the skull, raising up bosses of new bone from half an
inch to an inch in depth, on one or both the parietal bones, or on the
occipital or frontal. In some, all the bones of the face are involved in
similar changes. In some, similar elevations are produced by growth
of bone between the tables of the skull, which themselves remain healthy.
But as yet, I believe, we can only look at these as strange and unin-
structive things.
The last form of bony growths that I shall mention comprises the in-
stances in which numerous exostoses occur in the same patient, and the
examples of what has been called the ossific diathesis or dyscrasia. In
the large majority of cases, both cartilaginous and osseous tumors occur
singly : a few exceptions might be found among such as I have heen
describing, yet the rule is generally true. But in certain instances a
large number of the bones bear outgrowths which, at least in external
shape, are like tumors. These are commonly regarded as of constitu-
tional origin. Some, indeed, appear to be so in the sense of consti-
tutional disease, which implies a local manifestation of some morbid
condition of the blood ; but others can be so called only in that sense,
by which we intend some original and inborn error of the formatiTe
tendency in certain tissues or organs.
Of these last we may especially observe that the tendency to osseous
overgrowths is often hereditary, and that its result is a symmetrical
deformity. A boy, 6 years old, was in St. Bartholomew's Hospital,
* The specimen is in the Museum of St. Bartholomew's Hospital
DISTINCTIONS OF OSSEOUS GROWTHS. 488
several years ago, who had symmetrical tumors on the lower ends of
his radii, on his humeri, his scapulae, his fifth and sixth ribs, his fibulae,
and internal malleoli. On each of these bones, on each side, he had
one tumor ; and the only deviations from symmetry were that he had
an unmatched tumor on the ulnar side of the first phalanx of his right
fore finger, and that each of the tumors on the right side was rather
larger than its fellow on the left.
I saw this child's father, a healthy laboring man, 40 years old, who
had as many or even more tumors of the same kind as his son's ; but
only a few of them were in the same positions. All these tumors had
existed from his earliest childhood ; they were symmetrically placed,
and ceased to grow when he attained his full stature : since that time
they had undergone no apparent change. None of this man's direct
ancestors, nor any other of his children, had similar growths ; but four
cousins, one female and three male children, of his mother's sisters, had
as many of them as himself.
The swelling on the little boy's fore finger was an inconvenience to
him, and at his parent's request Mr. Lloyd removed the finger. The
swelling consisted of an outgrowth or projection of healthy-looking
cancellous bone, full of medulla, and coated with a thin layer of com-
pact tissue ; its substance being regularly continuous with those of the
phalanx itself.
Many similar cases of symmetrical and hereditary osseous outgrowths
might, I believe, be adduced ;"*" and all their history suggests that they
are to be regarded as rlslated not less closely to malformations, or mon-
strosities by excessive development, than to the osseous tumors or out-
growths of which I have been speaking. Indeed, at this point the
pathology of tumors concurs with that of congenital excesses of deve-
lopment and growth. We must distinguish from these cases the in-
stances of multiple ossifications of tendons, muscles, and other tissues,
that are occasionally met with ; for these only imperfectly imitate the
forms of tumors, and are probably connected with such a morbid con-
dition of the blood as really may deserve the name of ossific dyscrasia
or diathesis.
Before ending, it may be proper to point out the chief distinctions
between the osseous tumors and those growths which are connected with
other tumors springing from the bones ; for, under the vague name of
osteo-sarcoma, many include together, and seem to identify, all growths
in which bone is mingled with a softer tissue. •
The growths that may chiefly need distinction are those of osteoid
cancers, and the bony skeletons of certain medullary tumors of bone.
Osteoid cancers are probably examples of firm, or hard, or fibrous can-
* See Mr. Stanley's Treatise on Diseases of Bones, p. 152; and Mr. Hawkins's Lectures
00 TaiDon of Bones (Medical Gazette, vol. xxv, p. 474). Also a case reported in Med.
Timet aiid Gas., July 9th, 1853, from St. Bartholomew's Hospital, by Mr. J. Hutchinson.
484 GLANDULAR TUMORS.
cers, ossified : and the best marked among them present an abundant
formation of peculiarly hard bone. The distinctions usually to be ob-
served between these hard osteoid cancers and the hard osseous tumors
are mainly in these particulars: {a) the osteoid mass, in its mid-sub-
stance, may be compared with chalk, the osseous with ivory ; the one is
dull and powdery, the other bright, and wholly void of friability ; (6)
the osteoid is new bone infiltrated, as it were, in some softer tissue, or
in the tissue of the original bone, which disappears as it increases; the
hard osseous tumor is a distinct growth, attached in a comparatively
small part of its extent to the bone on which it grows ; (c) the outer
surface of an osteoid growth is porous and rough, and, if laminated, its
laminae have their edges directed outwards ; while the outer surface of
a hard osseous tumor is smooth and compact, and, if laminated, the
surfaces of its laminae are directed outwards ; (d) lastly, the minute
characters of bone are far less perfect in the osteoid than in the osseous
growth: bone-corpuscles existing, indeed, but small, round, irregular,
with very small, if any, canaliculi, and imbedded in a porous, chalky-
looking, basis-substance.
And, 2dly, for distinction between the softer osseous skeletons of
medullary cancers, and the cancellous osseous tumors, we may chiefly
observe that {a) the bone in cancers is more dry and friable than the
cancellous bone of the osseous tumors ; and {b) the bone in cancelloos
growths has no medulla, the interspaces between its laminae being filled
with cancerous matter ; while medulla is a constant constituent, I believe,
of all the cancellous osseous tumors.
Such are the chief differences generally to be observed between the
bone of innocent and that of malignant tumors ; difierences which it is
well to establish, since the fact is suflSciently confusing, that any nor-
mal tissue should be formed in subordination to the growth of cancers.
The subject will be again adverted to in the lecture on Osteoid Cancer.
LECTURE XXVIII.
PART 1.
GLANDULAR TUMORS.
Wb may call those tumors "glandular" which, in their structure,
imitate the glands ; whether the secreting glands or those organs which
we name glands, because, though having no open ducts, they are of
analogous structure.
The most frequent example of these glandular tumors is the kind
which imitates, and occurs in or near, the mammary gland ; the chronic
MAMMART GLANDULAR TUMORS. 485
mammary tamor of Sir A. Cooper ; the pancreatic tumor of Mr. Aber-
nethy;* the fibrous tumor of the breast of M. Cruveilhier.f Other
tumors of the same general kind are more rarely found in the lips, and
in or near the prostate and. the thyroid glands. Probably, too, some
other tumors, to which no name, or a wrong one, has been hitherto as-
signed, may yet hare to be placed in this group : indeed, I think it
nearly certain that there are lymphatic gland-growths, which we usually
regard as enlarged glands, but which are really new growths, of the
nature of tumors, even in the most limited sense of the term. At present,
however, I will have in view only such gland-tumors as may be clearly
recognized ; namely, such as the mammary glandular tumor, the labial,
the prostatic, and the thyroid.
Some of the pathology of these tumors has been already sketched
in the account of the glandular proliferous cysts (pp. 341 and 379). To
that account I may again refer, so far as to the point at which it is
believed that an intra-cystic growth has completely filled the cyst in
which its growth began, and has coalesced with the walls, so as to form
a solid tumor (p. 380).
fTow, it is perhaps probable that all glandular tumors may be formed
after this plan : for, in those occurring in the breast, we find sometimes
one circumscribed mass, composed half of a proliferous cyst, and half
of a solid glandular tumor ;X sometimes two such growths lie apart, yet
in the same gland (Fig. 49) ; and often, we find such structures as we
doubt whether to call proliferous cysts nearly filled, or mammary tumors
(Fig. 5).
However, if all the mammary and other glandular tumors are thus
of intra-cystic origin, it must be admitted that many of them very
early lose the cystic form, and continue to grow as solid masses ; for
we find them solid even when they are very small ; and they are traced
growing from year to year, yet apparently maintaining always the same
texture.
I shall speak now of the solid tumors alone ; and, first, of the Mam-
mary Glandular Tumors.
Sir Astley Cooper may be said to have had a good insight into their
nature, when he called them "chronic mammary,** and said they were
^^ as if nature had formed an additional portion of breast, composed of
similar lobes."§ The analogy of their structure was also recognized
by Mr. Lawrence. || But I believe nothing more than this general like-
•
* The mamniarj tumor described by Mr. Abernethy was probably a medullary cancer-
ous disease.
f Anatomie Pathol., liv. xxvi, pi. 1 ; and Bulletin de TAcad^mie de M^decine, t. ix,
p. 429.
X Mus. Coll. Surg., 177-8. § On Diseases of the Breast, p. 54.
II On Tumors; in Me<l.-Chir. Trans., vol. zvii, p. 29. It seems only just to observe that
diis recognitioci of the obvious resemblance between the structure of these tumors and that
of the mammary gland was almost always sufficient, after the description by Sir A. Cooper,
486 MAMMART OLANBULAR TUMORS.
ness had been observed, till these tumors were examined with the
microscope by M. Lebert,* who found in them the minute glandular
structure imitative of the mammary gland, and recognized many of
their relations to the proliferous cysts. Mi:. Birkett,t by independent
and contemporary observations, made on the great collection of these
tumors in Guy's Hospital, confirmed and extended the conclusions of
M. Lebert, and has cleared up much of the obscurity that existed pre-
vious to his inquiries. Both these gentlemen apply such terms as '^ Im-
perfect Hypertrophy of the mammary gland** to these tumors: but
highly as I esteem their observations (and not the less, I hope, because
they corrected errors of my own), J I would rather not adopt their no-
menclature, since if we do not call these "tumors,'* I hardly know to
what innocent growths the term could be applied. Nearly all innocent
growths are imperfect hypertrophies, in the same sense as these growths
are ; nay, these are, in many respects, the very types of the diseases
to which the name of tumors is by general consent ascribed, and which
can be distinguished, even in verbal definition, from what are more com-
monly regarded as hypertrophies.
The mammary glandular tumors may be found in any part of the
breast ; over, or beneath, or within the gland, or at its border; Their
most rare seat is beneath the gland ; their most common at its upper
and inner part, imbedded in, or just beneath, its surface. They are
usually loosely connected with the gland, except at their deepest part,
where their capsules are generally fastened to it ; but the connection
permits them to slide very easily under the finger, and to be peculiarly
movable in all directions.
The tumor is commonly of oval shape ; superficially, or sometimes
deeply, lobed or nodular ; firm, or nearly hard, elastic and often feeling
like a cyst tensely filled with fluid. The parts around appear quite
healthy. The mammary gland is pushed aside ; but it undergoes no
other change than that of atrophy, even when stretched over a tumor
of the largest size. The skin under distension may grow slightly livid,
but else is unchanged. The veins, if the growth of the tumor be rapid,
may be dilated over it, as over or near a cancer of the breast. The
tumor is usually invested with a complete capsule, isolating it from the
surrounding mammary gland, and often adhering less to it than to the
gland. This capsule may appear only as a layer of connective tissue,
to enable the surgeons of this country to avoid the confusion between the "chronic mammary''
tumors and the cancers of the breast, which M. Lebert describes as still prevalent in France,
notwithstanding his own clear description of the points of diagnosis.
* Physiologic Pathologique, t. ii, p. 201.
t On the Diseases of the Breast, p. 124.
J In the Catalogues of the Museums of the College and of St. Bartholomew's Hospital
these tumors are classed with the tibro-cellular. In most of the specimens that I bad ex-
amined the connective tissue was very abundant, and I thought too lightly of the glandular
tissue which I found mingled with it. The name adenoid sarcomata is sometimes applied
to these tumors of the mammary gland.
MAMMART GLANDULAR TUMORS. 487
like that around any other innocent tumor ; but it is not unfrequently
more perfectly organized in layers, and smoother on its inner surface ;
conditions that we may perhaps ascribe to its having been a perfect cyst
within which the glandular growth originated, and which the growth
has only lately filled.
On section, these tumors present a lobed construction, in which it is
sometimes not difficult to discern the remains, or the imitation of the
plan, of the lobed, or foliated and involuted intra-cystic growths. In
some, the connective tissue partitions among the lobes converge towards
the centre of the mass, as if they were the remains of clustered cyst-
walls ; or, there may remain a cavity in the centre of the tumor, as if
clustered cysts and growths had not quite filled up the space. In some,
however, no such plan is discernible; the whole mass is disorderly
lobed, and its lobes have the shapes derived from accidental mutual
pressure, and are bounded by loose partitions of connective tissue.
In structure as in construction, these tumors may present several
variations ; but they may be artificially arranged in three or four chief
groups.
Some are really very like the normal mammary gland in an inactive
state. These have a pure opaque- white, and soft, but tough and elastic
tissue ; they are lobed, and minutely lobulated, with undulating white
fibres. Such a one is well shown in a specimen from Sir Astley
Cooper's collection,* in which, moreover, his injection of the bloodves-
sels shows a moderate vascularity, about equal to that of the surround-
ing normal gland-substance.
We might take such as this as the examples of the medium form of
this kind of tumor ; and the other chief or extreme forms are repre-
sented by those which deviate from this in two directions. In one
direction we find much softer tumors ;t these, though closely textured,
are soft, brittle, or easily crushed ; their cut surfaces shine, or look
vitreous or half translucent ; they are uniformly grayish- white, or have
a slight yellowish or pink hue, which deepens on exposure to the air ;
or they may look like masses of firm, but flickering jelly ; and com-
monly we can press from them a thin yellowish fluid, like serum or
synovia. Such as these have the usual lobed and lobular plan of con-
struction; and I think the intersecting partitions commonly extend
from a firm, fibrous-looking central or deep part, towards the circum-
ference of the tumor.
In the other direction from the assumed average or medium form, we
find firmer tumors. These have a drier and tougher texture ; they are
opaque, milk-white, or yellowish, like masses of dense connective tissue,
lobed, and having their lobes easily separable ; as in the great specimen,
weighing seven pounds, in the College Museum (No. 208).
* Mas. Coll. Surg., No. 2772. In this specimen there is also a peculiar warty growth in
the akin over the tumor,
t Such as No. 2774 in the College Museum.
HAHHART QLANDULAR TUMORS.
Fig. 76.t
To such as these varietieB we might add many, due not merely to
intermediate forma, but to the degrees in which the intr^-cystic mode of
growth ia manifested ; or to the development of cjBta, which may take
place as well in this new gland-tisBne as in the old ; or to the variong
contents of these cysts, whether liquids or organized growths.*
I believe we cannot at present always connect these various aspects
of the tumors with any corresponding varieties in their historiee.
Neither, I think, have any inveatiga-
tions proved more of the corresponding
varieties of microscopic structure, than
that, as a general rale, the tougher any
tumor is, and the slower its growth has
been, the more it has of the connective,
mingled with its glandular, tissue ; while
the more succulent and vitreous one is,
and the more rapid its growth, the less
perfectly is the glandular tissue developed.
The microscopic structures may be
best described from a medium specimen :
from such a one I made these illustra-
tive sketches. The patient was S3 years
old ; the tumor had been noticed seven
months, and was ascribed to a blow ; it
was painful at times, and increasing ; aad
it had the several characters that I have
already described. The patient has remained well since its removal.
In such a tumor one finds, in thin sections, traces of a minute lobular
or acinous form ; the miniature, we might say, of that which we see
with the naked eye. The lobules may be merely placed side by side,
with little or no intervening tissue; their form may appear to depend
on the arrangement of their contents, and these may seem scarcely
bounded by membrane. But, I think, more commonly, especially Id
the firmer specimens, the plan of lobules or acini is mapped out by p«r-
titions of filamentous-logking tissue, fasciculi of which, curving sdJ
variously combined, appear to arch over, and to bound, each acinus or
lobule. But great varieties appear in the quantity of this tissue; it
may be nearly absent, or it may so predominate as to obscure the traces
of the essential glandular structure.
This proper gland-structure consists of minute nucleated cells «nd
nuclei, clustered in the lobular form, or in that of cylinders ar tabes,
* I believs iheae include the chief exatr
lumois containing simple eyas would con9
protirerous wilti gland growths would mn)i
t Fig. 75. MmuteBlruciiiresorainaini
nifled 3S0 limea. The microKopic exemi
Lebeil (Phya. Pathol., ii, 190; and Abhai
> of Milller's Cysto- sarcomata. One of lif
le his cypIo-sarcomB simplei', the cyan beiM
is cyslo-sarcoma phylloilos.
y glandular mmor, described in the leit ■ imp
ions of Bcveral specimens may be Ibuncl iii
Uuiigen, p. 269); Bitkelt, On Diseases of ibe
Breast, pi. '2, 3, 4, &c. ; and Bennett, On Cancsrogi aiut Cancroid Growths, p. 9S.
MAMMART GLANDULAR TUMORS. 489
and often, or perhaps always in their most natural state, invested with
a simple, pellucid, limitary membrane.
Thus, the likeness is striking between the structure of such a tumor,
and that of an inactive mammary gland, such as that of a male, as Mr.
Birkett has pointed out. We have here what may be compared with
the round or oval csecal terminations of the gland-tubes clustered to-
gether, and often seeming grouped about one trunk-tube ; and in these
we have the simple membrane and the gland-cells and nuclei within ;
only the main duct is wanting, and the communication with the ducts
of the proper gland. It is as if the proper secreting structure of a
gland were formed without connection with an excretory tube ; the
tumor is, in this respect, like one of the glands without ducts.*
The mammary glandular tumors are singularly variable in all the
particulars of their life. They sometimes grow quickly ; as did the
largest figured by Sir A. Cooper, which, in two years, acquired a weight
of a pound and a half. In other cases their growth is very slow ; I
have known onef which, in four years, had not become so much as an
inch in diameter. In some instances they remain quite stationary, even
for many years. One J was removed from a woman 27 years old : it
was observed for 14 years, and in all that time it scarcely enlarged ;
yet after this it grew so rapidly, that, in six months, it was thought
imprudent to delay the removal. Cases of this arrest or extreme re-
tardation of growth must have been seen by most surgeons ; but there
are few cases so striking as one related by M. Cruveilhier, in which a
lady had, for more than twenty years, three of these tumors in one
breast, and one in the other. She died in consequence of the treatment
employed against them, and after death no similar disease was found in
any other part.
Equal variations exist in regard to pain. Commonly these tumors
are painless ; but sometimes they are the seats and sources of intense
suffering; even of all that suffering which is popularly ascribed to
cancer, but which cancer in its early stages so very rarely presents.
The irritable tumor of the breast, as Sir A. Cooper named it, was in
most of his cases a mammary glandular tumor ;§ and the character of
the pain, like that of the painful subcutaneous tumor (p. 419), is such
as we may name neuralgic.
A tumor, II evidently glandular, was taken from the breast of a woman
twenty-five years old, where it had been growing for two years ; it had
* In one of these tumors, removed from abreast in which lactation was going on, Billroth
noticed that milk was secreted by the gland-like lobules of the tumor. — Virchow's Arcliiv,
1859, Tol. xviii.
f Museum of St. Bartholomew, Ser. xxxiv, No. 23.
t Mu8 Coll. Surg., 207 B.
S Under the same name, however, he included some that were more probably " Painful
subcntaneoiis Tubercles :'' see his pi. viii, figs. 2, 4, 5, 7.
I Mas. St. Barthoiomew's Hospital, Ser. xxxiv, No. 22.
32
490 MAMMART GLANDULAR TUMORS.
often been the seat of the most intense pain. I referred to a similar
case while speaking of neuralgic tumors (p. 420), and I removed a simi-
lar tumor from the breast of a young ladj, who begged for its removal
only that she might be relieved from severe suffering. In all these
cases the minute glandular structure was well marked.
A peculiarity of these tumors is, that they not unfreqnently disap-
pear ; an event very rarely paralleled in any other tumor. They are
most likely to do this in cases in which any imperfection of the uterine
or ovarian functions, in which they may have seemed to have their ori-
gin, is repaired by marriage, or pregnancy, or lactation. And the
fact is very suggestive : since, in many cases, it appears as if the discon-
tinuous hypertrophy, which constitutes the tumor, were remedied by
the supervention of a continuous hypertrophy for the discharge of in-
creased functions of the gland.
On the other side, these tumors often continue to grow indefinitely,
and they may thus attain an enormous size. One was removed by Mr.
Stanley, which, after twelve years' progress, in a middle-aged woman,
measured nearly twelve inches in length, and weighed seven pounds.
It was pendulous ; and, as she sat, she used to rest it on her knee, till
the integuments began to slough. Mr. Stanley merely sliced it off,
cutting through the pedicle of skin ; and the patient remained well for
at least seven years. The tumor was one of the firmest and most fila-
mentous of the kind.*
In the College Museum is a tumorf of the same kind, but softer and
much more succulent, which was removed by Mr. Listen from a woman
forty-four years old, and which weighed twelve pounds.
Respecting the origin of these tumors, little more, I believe, can be
said than that, occurring most commonly in young unmarried or barren
women, their beginning often seems connected with defective or disor-
dered menstruation. The law which, if we may so speak, binds to-
gether in sympathy of nutrition the ovaries and the mammary glands,
the law according to which they concur in their development and ac-
tion, is not broken by one with impunity to the other. The imperfect
office of the ovary is apt to be associated with erroneous nutrition in
the mammary gland.
I have seen only one specimen of the mammary glandular tumor in
a male. A portion of it was sent to me by Mr. Sympson, and its charac-
ters were well marked. It was removed by Mr. Hadwcn, from a coun-
tryman, twenty-five years old, in whom it had been growing regularly,
and occasionally diminishing or disappearing, for about five years.
When removed, it formed a circular, flattened, and slightly lobulated
tumor, 3J inches in diameter, and an inch in thickness, invested with a
distinct connective-tissue capsule, which loosely connected it to the adja-
cent tissues.
* Mils. Coll. Surg., No. '208. f Mus. Coll. Surg., No. 216.
MAMMART GLANDULAR TUMORS. 491
There are, I believe, no facts to suggest that the glandular tumors
are, as a rule, other than innocent. More than one may grow in a
breast at the same or several successive times ; but I have not known
of more than three either at once or in succession. Neither am I aware
of any facts which prove what is commonly believed, that, after a time,
these tumors may become cancerous. Such things may happen ; and,
on the whole, one might expect, that if a woman have a tumor of this
kind in her breast, cancer would be more apt to affect it as a morbid
piece of gland, than to affect the healthy gland. But, I repeat, I know
no facts to support this ; and some that I have met with are against it.
Thus, in the Museum of St. Bartholomew's, is a portion of breast,*
from a woman thirty-two years old, in which there lie, far apart, a
small mammary glandular tumor that had existed four years, and a hard
cancer that had existed four months. A second specimenf shows a
hard cancer and a proliferous cyst, in the breast of a patient, who died
some time after its removal, with recurrence of the cancer ; and I be-
lieve that they are not counterbalanced by any of an opposite kind.
And yet, while all the characters of innocent tumors are generally,
if not always, observed in these, there are facts concerning a seeming
connection between mammary glandular tumors and cancer which must
not be passed by here ; though they may need to be again stated in the
last lectures on cancer.
It has sometimes happened that a glandular tumor has been removed
from a breast, and, within a short time, the same breast has become the
seat of cancer.^ I believe that the explanation of such cases as these
may be, that a woman, prone to cancer by some constitutional condi-
tion, or, especially, by hereditary disposition, had (as any other might)
a glandular tumor in her breast ; and that the operation for removing
this tumor inflicted a local injury, and made the breast apt to be the
seat of cancer, of which already (as one may say) the germ existed in
the blood. Such events may prove only an accidental connection be-
tween the glandular tumors and the cancer ; but they are enough to
suggest great caution in operating on the breasts of those who may be
suspected to be, by inheritance, peculiarly liable to cancer.
But, again, cases sometimes occur in which, I think, the mammary
glandular tumors supply examples of what I have already suggested as,
probably, a general truth : namely, that the children of a cancerous
parent, or those in whose family cancer is prone to occur, are apt to
have tumors which may be like innocent tumors in their structure, but
may resemble cancers in a peculiar rapidity of growth, and a proneness
to ulceration and recurrence after removal. A striking instance of this
occurred in Mr. Lawrence's practice. He removed the breast of a lady,
from one of whose sisters Mr. Aston Key had removed a breast said to
* Ser. zjcxiT, No. 17. f Mus. St. Bartholomew's Hospital, Ser. xxxiv, No. 16.
X See aoch a case, by Mr. Erichsen, in the Lancet, Feb. 14, 1852 ; and the history of a
series of preparations in the Catalogae of the Museum of St. Bartholomew's, vol. i, p. 446.
492 LABIAL GLANDULAR TUMORS.
be afTected with ^^ fungoid" disease, whose mother had died with well-
marked hard cancer of the breast, and in other members of whose family
cases of cancer were believed to have occurred. The breast removed
by Mr. Lawrence comprised a huge sloughing and ulcerating mass of
yellowish, soft, flickering substance, like the softest of these mammary
glandular tumors, or like the very soft pellucid growths which I have
described as occurring in some of the proliferous cysts of the breast.
The diseased state of the mass (in consequence of escharotics having
been recklessly used) was such, that minute examination showed little
more than the absence of distinct cancer-structures. During the heal-
ing of the wound, and for some months after it, fresh growths re-
peatedly appeared. Some of these which I have examined were yellow,
pellucid, soft, viscid, almost like lumps of mucus, or of half-melted gela-
tine, imbedded in the tissues of the integuments or scar. With the
microscope I found only granules and granule-masses, with elongated
nuclei, themselves also granular, set in abundant pellucid substance. I
found no sign of cancer-structure or of gland-structure. The substance
resembled that which I have mentioned (p. 883) as found in some of the
imperfect proliferous mammary cysts.
Now, after repeated removals of such growths as these, the wounds
completely healed, and the patient has remained well, and in good gene-
ral health, for eighteen months.
At nearly the same time, a third sister of this family was under Mr.
Lawrence's care, and he removed one of her breasts in which was a great
mass, which had grown quickly, and was chiefly composed of well-
marked glandular tissue, either in separate solid growths, or inclosed in
proliferous cysts. But some parts also of this tumor were soft, pellucid,
and gelatinous ; and others were as soft, but opaque and dimly yellow.
In the firmer parts, the glandular texture was as distinct with the mi-
croscope as with the naked eye : in the softer parts no such structures
were seen, but abundant free cells and nuclei, of most various and
apparently disorderly shapes ; some elongated, like small shrivelled
fibro-cells ; some flattened, like small epithelial cells. I would not ven-
ture on an opinion of what these were or indicated ; I think they were
not cancerous, and the disease has not returned. The main fact of all
the cases is, that three daughters of a cancerous mother had mammary
tumors ; in two, at least, of them the structure was probably not can-
cerous ; and yet the rapid growth, the recurrences in one of them, and
the defective or disordered modes of growth in both, were such as marked
a wide deviation from the common rules of mammary glandular or any
other innocent tumors, and a deviation in the direction towards cancer.
Labial glandular tumors may be briefly described, for their gene-
ral characters correspond closely with those of the foregoing kind ; or,
they may appear intermediate in character between the foregoing and
those tumors which I described as lying over or near the parotid gland,
LABIAL QLANDULAB TDH0R8.
and aa consiatiDg of mixed glandular and cartilaginous tissue. Their
likeness to tbese tumors over the parotid was manifest to Mr. Lawrence,
«bo has added to bis aocount of the tumors by the parotid, the only
case of labial glandular tumor that I have found on record.*
The most marked case of labial glandular tumor that I have seen was
that of a healthy-looking man, some years ago, under tbe care of Mr.
Lloyd. A tumor had been growing in his upper lip for twelve years.
It was not painful, but the protrusion of the lip was inconvenient and
ngiy, the swelling being an inch in diameter. It was imbedded in the
very substance of tbe lip, both tbe skin and mucous membrane being
t«neely stretched over it. Its form was nearly hemispherical, its pos-
terior Burface being flattened as it lay close on the gums and teetb, its
anterior convex and smooth. Its whole substance was firm, tense, and
elastic.
Mr. Lloyd removed tbe tumor with the mucous membrane over it,
leaving the skin entire. The tumor was firm, slightly lobed, yellowish-
white, smooth. In general aspect it resembled the mixed tumors over
the parotid, but in minute structure
it presented as perfect an imitation
of lobulated or acinous gland-struc-
tnre as any mammary glandular tu-
mor. Its tubes and their dilated ends
had distinct limitary membrane, and
were filled with nuclei and nucleated
cells, like those of tbe labial glands
(Fig. 76). I heard some months after-
wards that another tumor was grow-
ing in tbe same lip ; but the patient
was lost sight of. Such a recurrence,
even if it really happened, would be
no sufficient evidence of mnlignancy.
I removed a similar tumor from the
npper lip of a man about 30 years
old. It had been regularly growing
for four years without pain, and pro-
jected far externally, reaching to the
same distance as the end of his nose.
This had a texture of glandular kind,
bnt less distinctly marked than that
in the former case. Moreover, in the
centre of tbe mass was a portion of
0 -5 « 9©
• Medi(!0-Chirurgi™lTninsBC(i
t Fig. 16. A, ittuclure like (he i
nte portiOD ot Kland-like lube ; c
gtandnlar tumor deicribed in llie
and
i>, p. 28.
iBiionaofKlaiKl-ducis
ilard-cBlls, BniJ free
B magnilied 300 t
494 PROSTATIC AND THTROID GLANDULAR TUM0R8.
bone; a peculiarity which existed also in Mr. Lawrence's case, and
which may add to the probability of relationship between these tumors
and the mixed glandular and cartilaginous tumors over the parotid.
Lastly, I may again refer to a specimen in the Museum of St.
George's Hospital, in which, in one tumor, a cyst and what looks like
one of these glandular growths are combined (see p. 384).*
Prostatic glandular tumors were briefly referred to in the first
lecture on tumors (p. 342), as examples of the abnormal growths by
which tumors appear to be connected with simple hypertrophies of
organs ; and I can add little to what was then said of them.
We owe to Rokitanskyf the knowledge that the tumors in the pro-
state gland, which were commonly, and till lately even by himself, re-
garded as fibrous tumors, are composed of tissues like those of the pro-
state gland itself. In enlarged prostates they are not unfrequently found.
In cutting through the gland, one may see, amidst its generally lobed
structure, portions which are invested and isolated by connective tissue,
and may be enucleated. Such portions have, I believe, been sometimes
removed as tumors, or as portions of prostate gland, in operations of
lithotomy. They lie imbedded in the enlarged prostate, .as, sometimes,
mammary glandular tumors lie isolated in a generally enlarged breast.
They look like the less fasciculate of the fibrous tumors of the uterus;
but, to microscopic examination, they present such an imitation of the
proper structure of the prostate itself, that we cannot distinguish the
gland-cells or the smooth muscular fibres of the tumor from those of the
adjacent portions of the gland. Only their several modes of arrange-
ment may be distinctive.
At present the examinations of these tumors have been too few to
furnish a complete history of them : neither can I add any cases or
references to those which were adduced in the first lecture.
The thyroid glandular tumors were similarly referred to in the
same lecture. Their history is merged in that of bronchoceles, with
which they are usually associated, whether imbedded as distinct masses
in the enlarged gland, or lying close by it, but discontinuous. Yet I
suspect that similar growths, of substance like thyroid gland, may
occur, as tumors, further from the normal mass of the gland.
Mr. Stanley removed a tumor from the neck of a woman 62 years
old. It had been observed for fifty years ; for the first thirty of which
it was like a little loose '^ kernel" under the skin, and scarcely in-
creased. In the next ten years it grew more quickly, and in the next
ten more quickly still ; and now, the skin over it ulcerated, and it pro-
* Billroth relates a case in which one of these tumors grew in connt-ction with the mu-
cous membrane of the cheek, about one inch from the angle cf the mouth. It was removed,
and twice recurred after the first extirpation. Virchow's Archiv, vol. xvii, p. 374.
f Ueber die Cyste, 1849 j and, Anntomie desXropfes.
EBIOTILE OR VASCULAR TUMORS. 495
tmded and occasionally bled, but was never painful. It looked like an
ulcerated sebaceous cyst, seated upon a subcutaneous tissue at the lower
part of the neck, just in front of the trapezius. No cause could be
assigned for it.
On section it appeared as a solid tumor with a thin connective-tissue
capsule, partitions entering from which divided it into distinct round
lobes. Its proper substance was. soft, elastic, glistening, yellowish,
blotched and streaked with brownish pink and blood colors. It was, to
the naked eye, like a piece of bronchocele, with such an arrangement
of its parts as would exist when numerous cysts are filled with the
glandular growth, and compacted. And the general impression hence
derived was confirmed by microscopic examination, which showed that
the tumor consisted, chiefly, of round and oval bodies, or minute sacculi,
from Too^^ ^^ nin^^ ^^ ^^ ^^^^ ^^ diameter, filled or lined with nucle-
ated substance, or with nuclei imbedded in a dimly molecular blastema,
and not nucleolated. These bodies were closely apposed, but frequently
appeared separated by thin filaments, or connective-tissue partitions.
The nuclei were very uniform, circular, about ^ouu^^ ^^ ^^ ^^^^ ^^ ^^^
meter, and in general aspect like the nuclei of vascular glands or
lymph glands. Numerous similar nuclei appeared free ; and some ap-
peared imbedded in a dimly molecular blastema which was not inclosed
in cysts or sacculi, nor divided by partitions of connective tissue.
I have seen no other tumor like this ; nor any natural texture that
it resembled except the thyroid gland. Future observations must
prove whether thyroid glandular tumors can be formed so far from
the normal gland, with the cervical fascia, great bloodvessels of the
neck, and other adjacent parts, intervening between them.
LECTURE XXVIII.
PART II.
ERBCTILB OR VASCULAR TUMORS.
Thb ERBCTILB OR VASCULAR TUMORS include most of the diseases
which are described as vascular naevi, and of whicK the types are the
subcutaneous naevi. Among them, also, are the growths to which John
Bell gave the name of aneurism by anastomosis, and those which have
been called Telangeiectasis.
The name " erectile tumor" has, of late years, come into general use,
as expressing a principal fact concerning these diseases, — namely, that
many of them resemble very closely in their texture that of erectile or
cavernous tissue. Dr. Humphry* has, indeed, righly objected to the
* Lectures on Surgery, p. 111.
John BdVs
itt of the
use of the temi, that these tnmors present no imilKtion of tbc trtetSt
tJHsuc in the power of fiUin;; themselves with blood, its if by torn* mur-
nftl force. But, since this occurrence in the trn<? erectile tiMtte dcfxwfa
as much on the accessory structures of nerves and muscles ka <n lb«
tissue itself, we nmy fairly apply the term "erectile" to tb«
remembering only for this, as for other structures occurring in
that the imitation of the natural tissue is imperfect, or partial. Ho*
ever, if any be scrupulous in the use of these terms, they may esU ibn
tumors vascular, or cavernous, or even TelangeifClasis.
The likeness which these tumors bear to the erectile tissue, ■■ «»•■
plilied in the corpus cavGrnoauin penis, is sometimes, in general •|>fMr-
ance, perfect. A well-marked specimen is in the IIunterisD colleolaoa,*
from which the adjoining sketch was made (Fig. 77). It was renofij
from under the lower jaw, and its cut surface displays a close netmk
or sponge of fine, smooth, shining bands and cords, just like tbtwrf
the corpus cavernosum penis, only less regular in their arrsngimBt.
The opportunities of examining such tumors in the recent iiat* SN
very rare ; and they are usually spoiled by the operations for renoii^
them ; but what I have seen, and the descriptions which othen hiti
recorded, leave little doubt that this imitation of erectile tisstte iitfiv
(juent character among them.
neurism by anastomoaia, which it b|
far the most vivid and eiact. in re-
lation to the liistory of the discait,
that has yet been published, acc«Hi
with this statement. Althtngli bt
bad chiefly in view tlie artwiil
variety of these tumors, yet of bo<
ho says, " The subsianoe of il •»
ct'llular. stringy, and exactly n*
.-4cu)bling the corpora canrM*
jK'Tiia , . . the cells were filled •!*
Idnod from the arteries, which «<•
lered the tumor in all direeooai.
Another he compares to a Hponp
sijiikfd in blood; and the ieKnf
lions of fither examples, though I*
explicit, imply the same, Th» if-
acriplions by Mr. Wardropt W
Mr. Ciesnr Hawkins,!! ami the nm
minute accounts of strucHtr* tf
• Mut. Coll. SurK.,.101 k.
J Fif. 77. S«--i>On or 81. rriK'iile lumoi
ItRwti une-thinl tutget, aiiil mhrt ihhiim
1 M«L-Clikl. Tnn*,, not. i>, y. SUl, ■!
I Medkal OixeiiF. vrtl. ixini, p. Kfi:
L ^ .
BRBOTILE OR VASCULAR TUMORS. 497
Mr. Goodflir,* and Mr. Listonf and Rokitan8ky,J confirm this view ;
and neither Mr. Birkett's,§ nor any other that I have met with, is dis-
cordant from it.
The essential structures of the disease are, according to these de-
scriptions, derived from such a growth of bloodvessels, or rather of
blood-spaces, that, in imitation of erectile tissue, the whole mass seems
formed of cells or spaces, opening widely into one another : and, in ex-
treme cases, no remains exist of the walls of the vessels, except those
narrow bands and cords that bound and intersect the cell-like spaces. ||
The division, often made, of erectile or vascular tumors into such as
are named, respectively, " arterial," " capillary," and " venous," is con-
venient, and probably well-founded. The most frequent examples of
subcutaneous naevi, and the more frequent superficial nsevi, which are
like them in structure, though different in position, appear to consist,
mainly, of closely arranged minute bloodvessels, of which some are as
small and as simple as medium-sized capillaries, while others, of various
size, appear as dilated capillaries, or as small arteries and veins densely
clustered, but in just proportions to one another. These are such as
may be called " capillary ;** understanding, only, that they probably
affect minute arteries and veins as well as capillaries. But, on the one
hand, deviating from these specimens, we find that in some cases the
enlargement of arteries far exceeds, in proportion, that of the veins ;
the swellings pulsate, and are florid and over-warm, and, if injured,
throw out arterial blood. These constitute the " arterial" form of the
disease: the "aneurism by anastomosis." And, on the other hand,
are tumors formed mainly of dilated, sacculated, and overgrowing veins ;
to these, arteries of comparatively small size pass, while from them
proceed very large veins : and they are subject to changes of size in
all the events that affect, not the arterial, but the venous, part of the
circulation.
Now, I believe that, in a majority of cases, the arterial and the venous
forms of the disease are constituted by a dilatation of large branches,
of one or the other kind, being superadded to such a condition of the
small vessels and capillaries as exists in the common, or " capillary"
erectile tumors. But I have, also, no doubt that, in rarer instances,
arterial tumors are formed by arteries alone, convoluted or anastomos-
ing in a heap, whence, as from an arterial " rete mirabile," normal
♦ Northern Joura. of Medicine.
f Med.-Cbir. Trans., vol. xxvi, p. 125.
J Pathologiache Anatomie,i, 276.
{ Med.-Cbir. Trans., vol. xxx, p. 193.
I What tissue may remain between the bloodvessels depends on the seat of the naevus.
The elements of the organ or tissue in which it has its seat will remain between its vessels^
wasted or altered by compression or defective nutrition. They are seldom present in any
distinct form ; but a case is well described by C. O. Weber, in which abundant fibrous and
Uaty tissue occupied the space between the dilated vessels of an erectile tumor in a child's
neck (M&ller 8 Arcbiv, p. 74).
498 CAPILLART VASCULAR OR BRBGTILB TUMORS.
arteries proceed and lead to capillaries. And, on the other hand, there
are, doubtless, venous tumors, which are formed of veins alone, and
through which, since they are seated altogether beyond capillaries, the
blood passes (according to Rokitansky's comparison) as it passes through
a portal vein.
. Since few accounts of the minute characters of the erectile tumors
have been published, I will briefly describe those which I have examined,
beginning with an instance of the medium form, in a capillary subcu-
taneous nsBvus.^
A child, 2 years old, which had a nsevus of this kind on the side of
the chest, died exceedingly emaciated after measles and diarrhoea. The
tumor had grown from birth-time, and had appeared as one of the
most ordinary subcutaneous nsevi or erectile tumors ; soft, compressible,
dimly blue as seen through the skin, swelling in forced expiration,
thinly scarred over its centre, in consequence of an vicer which had
spontaneously formed and healed. After death it had shrunk into a
very thin layer of brownish tissue between the emaciated skin and the
fascia covering the serratus magnus. It was well defined, and could
be dissected out cleanly from the adjacent parts. Its surfaces and
sections had a distinct lobular arrangement, many lobes projecting from
its borders, and those within it being separated by connective-tissue
partitions derived from the tough skin and fascia between which the
tumor lay. In its shrunken state, it most resembled, in its obvious
characters, a piece of parotid gland ; being pale brown in color, lobu-
lated, soft, but tough, and yielding but little blood on pressure.
About six small collapsed veins proceeded, in a tortuous course, from
the surfaces and borders of the tumor. Its arteries were too small to
be distinct. Examined with the microscope, the whole mass appeared
composed of bloodvessels interlacing in white and yellow fibrous tissue,
which probably belonged to the natural subcutaneous structure. No
parenchymal cells or abnormal forms of tissue were found ; the disease
seemed to be of the bloodvessels exclusively.
The vessels, which were very difficult to extricate, in any length, from
the matted tissue about them, were of all sizes, from 5000^^ ^^ soo^'^ ^^
an inch in diameter ; but I think none were larger. Nearly all of them
were cylindriform ; a few were unequal, or varicose, or sacculated, with
small pouched projecting from their walls (Fig. 78). I could not discern
their arrangement ; but they did not appear to branch often ; neither
am I sure that they difiered in structure from the normal vessels of
subcutaneous tissue, except in that they were, considering their size, of
less complex structure : they were as if minute vessels were enlarged
without acquiring the perfect form of those which they equalled in
* All the specimens described are in the Museum of St. Bartholomew's Hospital.
CAPILLARY YASCULAB OB BRECTILB TUMOBS.
499
Fig. 78 .♦
i«
1
1
I
i^<S^^
ealibre. In some parts, I found long cords of connective tissue, which,
probably, were obliterated bloodvessels.
I have examined other tumors resem-
bling this, but in less favorable conditions.
From all, however, as well as from the de-
scriptions of others, I believe the common
structure of this form of erectile tumor is
a collection of minute bloodvessels, dilated,
and closely arranged within a limited area
of some natural texture. In the subcu-
taneous tissue, arteries usually appear to
pass into the vascular mass from the under
surface of the skin ; and veins radiate from
it, larger than the arteries and more numer-
ous, but scarcely exceeding the proportion
between the normal cutaneous veins and
arteries. Within the tumor (which thus, as
well by the relation of its vessels as by their
minuteness,justifies the epithet '^capillary")
it is probable that some of the vessels are always sacculated or varicose.
Virchow'sf account of this state exactly confirms what I have described ;
and, with more detail. Robing describes an erectile tumor in which,
along the track of the vessels, numerous little culs-de-sac existed,
which the blood might be made at will toenter and quit, by alternately
pressing and letting free a piece of the tumor on the field of the micro-
scope. These could be seen on vessels as small as ^th of a millimetre
in diameter ; they were generally smaller at their connection with the
vessels than at their other ends, and were commonly twice as long as
the vessels were wide.§
But although the vessels within the tumor be thus dilated, yet, as a
general rule, in this form of the disease, the dilatation (if there be any)
in those proceeding to and from the tumor extends but a short distance
from it : the arteries enlarge (if at all) only just before they enter the
tumor; the veins regain their calibre soon after they leave it: and
hence the general safety with which John Bell and many others have
cut out such tumors, when they attended to the rule he lays down with
♦ Bloodveraels of the erectile tumor described in the text. Magnified about 200 times.
f Archiv, ftir Pathol. Anatomie, B. iii, p. 437.
} In Lebert; Physiologie Pathologique, t. ii, p. 90.
$ It may perhaps be well to apply, as is now generally done by pathologists in Ger-
many, the term Telangeiectasis to these ncevi materni. An excellent description of them is
given by Billroth, in his Untersuch. Qber die Entw. der Blutgef'asse, p. 60, 1850, which con-
firms what id stated in the text. He considers them as altogether formed of bloodvessels,
pertly new-formed and partly the normal vessels of the cutis enlarged and dilated. In the
blne-oolored neevi, the vessels especially enlarged are, those of the sebaceous and sweat-
glands, the hair-follicles, and subcutaneous fat-lobules. In the bright-red nu'vi, again, the
retaelv enlarged are those of the papillte of the cutis ; and here, instead of a single loop in
each papilla, as in the normal condition, a perfect network of loops is met with.
500 ARTERIAL VASCULAR TUMORS.
such emphatic repetition, that in treating such a tumor we are " not to
cut into it, but to cut it out.** However, this limitation of enlargement
to the vessels within and near the tumor, is not so usually observed in
the next two forms of the disease, as in this which I have just described.
The best example of the arterial erectile tumor, that I have been
able to examine, was from a man who died under the influence of chlo-
roform at St. Bartholomew's Hospital. He was 23 years old, and the
disease occupied the external ear, the adjacent subcutaneous tissues,
and part of the scalp. The back of the auricle, in nearly the whole ex-
tent, was puffed out by a superficially-lobed, soft, easily compressed,
and elastic swelling, which all pulsated fully and softly. Two similar
and continuous lobes of swelling were under the scalp above and behind
the auricle ; and these were well defined above, but gradually subsided
below. The skin covering the swelling was for the most part dusky
purple, but, except where it was scarred, appeared of healthy texture ;
the skin of the interior of the auricle and its fibro-cartilage also appeared
unaffected, except in the turgescence of the bloodvessels. A posterior
branch of the superficial temporal artery passing by the front of the
swelling, and a branch of the posterior auricular artery passing behind
it, felt large, and pulsated strongly ; the common carotid artery, also,
on this side, pulsated more fully than that on the other. A distmct
soft bruit was audible, synchronous with the pulsation in the tumor;
and distinct pulsatile movement was visible.
This disease had been noticed like a very small pimple when the
patient was 4 years old. It had from that time regularly increased.
On four occasions severe bleeding had taken place from it, through an
ulcer in the skin over it, or through a prominent part over which the
skin was extremely thin. After the first of these bleedings a piece of
the swelling had been tied, and had sloughed away. A month before
the patient's death, Mr. Lloyd had tied and compressed the branch of
the temporal artery and two other principal arterial branches at the
borders of the swelling ; and by this and subsequent treatment had di-
minished the size of the tumor and the fulness of the pulsation in and
around it.
Much of the tumor had been spoiled by this treatment, but enough
remained to show that a great part of its substance was like that last
described, and probably, like it, consisted of minute bloodvessels col-
lected in a soft spongy mass. But, while the veins proceeding from
the swelling were of no considerable size, the arteries passing to it and
within it were very large, convoluted, and thin-walled. This was espe-
cially observed in the posterior auricular artery, which had not been
interfered with in the operations. A lobe of the swelling (as it seemed)
had pulsated strongly below and behind the lobule of the ear ; and it
was for the operation of tying this that the chloroform was given to the
patient. This proved to be only a part of the posterior auricular artery,
J
ABTBBIAL VASCULAR TUMORS. 501
which, from a short distance beyond its orgin, was large, and more col-
lapsed and flattened than the other branches of the external carotid.
At the beginning of its enlarged part, this artery was from a line to a
line and a half in diameter ; and from this point its trunk, as well as its
branches (which were not unnatural in either number or anastomosis),
were tortuous and coiled up in heaps, which had felt during life like
pulsating masses. The dilatation of the arteries was uniform, not sac-
culated, though in parts the suddenness of the curves made it appear
so. The small intervals between them were filled either with the
natural connective tissue, or with the minute bloodvessels that composed
the chief mass of the tumor.
I believe that this specimen presented a fair example of the ordinary
structure of the arterial form of vascular or erectile tumors ; and that
they consist, essentially, of the minute vessels of a limited portion of
tissue enlarged and closely clustered, so as to form a tumor, in the sub-
stance, as well as about the borders, of which are arteries much more
enlarged, and convoluted into pulsating heaps.
The existence, and even the preponderance, of the minute vessels in
such tumors was manifest in a specimen sent to me by Dr. Ormerod.
A healthy woman, about 60 years old, had for many years a pendulous
growth in the lower and inner part of the left axilla. Lately it had
grown quickly to the size of the closed hand. It was dark, hard, and
knotty, with a distinct pulsation, and hung on a pedicle in which a
large artery could be felt. A ligature was tied on the pedicle, and a
few hours after another was applied, and the pedicle was cut through.
The tumor was gorged with blood, ecchymosed, and too much da-
maged for complete examination. Its general aspect was like that of the
pedicled outgrowths of skin ; but nearly its whole mass consisted of
minute bloodvessels confusedly arranged and of various sizes. Their
walls showed nuclei, which were generally shorter than those of healthy
arteries ; but in many instances were placed, as in them, regularly in
layers, the external lying longitudinally, others within these trans-
versely, and, still within these, others that were obliquely or variously
placed. Besides the bloodvessels, I could find in the tumor only a com-
paratively small quantity of connective tissue ; and Dr. Ormerod' s ex-
aminations, made when the tumor was more recent, had similar results.
Some, I think, have described the arterial tumors as formed by the
convolutions of a single artery ; and the characters of the swelling formed
by the trunk and commencing branches of the posterior auricular artery,
in the first of these cases, make me ready to believe that this descrip-
tion may be sometimes true. But I think that, more commonly, many
branches of arteries are engaged in the tumor. Such was the case in
the tumor of the ear, and in an instance recorded by Mr. Coote.* Ar-
teries of the lip, which, in their natural state, might not have had a
* Medical Gazette, vol. xlv.
502 VBNOUS VASCULAR TUMORS.
greater diameter than a large pin, were dilated for about an inch of
their course into sinuses or canals, and were equal in diameter to the
adult radial artery. Similar to this was a very formidable case, cured
by compression, under the care of Mr. Lloyd. The temporal, supra-
orbital, and occipital arteries, all exceedingly dilated and tortuous, con-
verged to a large pulsating swelling over the sagittal suture, the gene-
ral characters of which agreed exactly with what I have described.
In the arterial vascular tumors the veins are comparatively small ;
and the difficulty of transit for the abundant blood flowing into them,
doubtless adds materially to the fulness of the tumors, and of the pul-
sations seen and felt in them. In the venous tumors the opposite con-
dition obtains ; the veins are very large, the arteries comparatively
small. Of this kind of tumor the following case presented a good ex-
ample.
A man, 32 years old, was under the care of Mr. Lawrence. He had
a hoof-shaped tumor projecting from the middle of the outer part of his
thigh. It was from six to eight inches in diameter, and looked like
some strange outgrowth of skin. Its base rested on the fascia lata;
it was covered with skin, which was healthy, except in one excoriated
place, and adhered closely to it. It was firm, but compressible and
elastic, and by long-continued pressure could be reduced to nearly half
its size, as if by squeezing blood from it. Several small arteries pul-
sated at its base ; and very large veins, like tortuous sinuses, converged
from it towards the upper part of the saphena vein.
The patient was in feeble health, apparently through the eflFect of a
life in India, where, in the army, he had received a wound by a musket-
ball, to which he referred as the cause of the growth of this tumor.
Before the wound, he believed the part was quite healthy. The injury
appeared superficial, and he was absent from duty only two days ; but,
six months afterwards, he observed a small tumor, and this, growing
constantly and with severe pain, had increased in ten years to the pre-
sent mass. The skin had been slightly ulcerated for twelve months,
and severe hemorrhages had occurred from the ulcerated part, reduc-
ing his already diminished strength.
Mr. Lawrence cut away the whole tumor. Its connections were
slight, except to the skin covering it ; the arteries at its base bled freely,
but for a short time ; the great veins bled very little.
A section through the tumor shows that, while some parts of it ap-
peared solid and close- textured, like a mass of firm connective tissue,
the greater part was like the firmest cavernous or erectile tissue. Sec-
tions of bloodvessels, of various sizes and in various directions, were so
thickset, that the surface looked all reticulated and grooved with them.
The general color of the tumor, which seemed to have almost emptied
itself of blood during the operation, was nearly white ; but in some
KRBGTILE OR YASGULAK TUMORS. 508
parts it had a pale ruddy tinge, and in a few was blotched with small
rusty and ochrey spots.
The microscopic examination was less instructive than the general
aspect of the tumor. Its tissue was very hard to dissect, and displayed
(as its chief constituent) matted and crooked fibres, like those of close-
textured longitudinal striated membrane of bloodvessels, with shrivelled
nuclei imbedded in membrane, some of these nuclei being round, some
oval, and some very narrow and elongated. I think the obscurity of
the microscopic appearances was due to the tenacity with which the
bloodvessels were imbedded in the elastic fibrous or nucleated tissue ; it
seemed impossible to extricate complete vessels ; and one obtained by
dissection only fragments of their walls confused with the intermediate
tissues.
Other cases of venous naevi, which I have been able to examine less
completely, have confirmed the foregoing account, especially in regard
to the small size of the arteries in comparison with the veins, the gene-
rally dilated and varicose state of the latter, and the imitation of the
characters of erectile tissue, which appears always more marked in the
venous than in the other forms of vascular tumors. "*"
* The term ** cavernous'* is especially applicable to such tumors as have been described
in the text by the name of venous vascular tumors, and it is very much in that sense that
it baa been employed by various pathologists in Germany. If we are to accept the views
ofRokitansky (Sitz. Bericht der Kais; Akad der Wissen, 1852), there would appear, liow-
ever, to be two forms of tumors included under the name of cavernous, viz., 1st, tliat form in
which the tumor consists essentially of the bloodvessels of a certain area, dilated, sacculated,
fenestrated, with mutual communications ; and 2dly, that in which the tumor is a new-
formed cystic, and tubular, or cavernous structure, in which the cavities are filled with blood.
The tumors described in the text undoubtedly belong to the first of these divisions ; so also
do those cavernous tumors in the liver described by Virchow in his Archiv, vol. vi, p. 525.
In his account of these tumors, Virchow points out that the cavernous tumor of the liver
grows in the place of, and substitutes, certain groups of the acini ; that the whole vascular
system of the part of the liver thus afiected, gradually forms a cavernous '*ektasie," which
stands in direct communication with the veins and arteries, without any particular capillary
apparatus being recognizable ; that the process begins with an increase of the intermediate
connective tissue of the liver, which is soon followed by a wasting of the secreting structure ;
that in this tissue, which in the beginning is abundantly nucleated, the vessels dilate, their
walls thicken, and blend with the surrounding connective tissue, and that then, with the
increasing dilatation of the vessels, their walls and the intermediate tissue atrophy, and in
inseparable connection form the bars of the tumor. A case, described by Esmarch in Vir-
chow's Archiv, vol. vi, p. 34, of multiple cavernous tumors of the hand and arm, belongs
also, apparently, to the same group. So also does the case by Afaier, in Virchow 's Archiv,
vol. viii, p. 129, which almost precisely agrees with the one described above, in the text
His description is more minute as to the component structures of the intervening bands and
bars, and more perfectly shows them to be, or to include, venous structures. To these cases
may be added one related by Busch (Chir. Beobacht, 1851, p. 213).
To the second division, in which the tumor is a new formation of a blood-containing
cavernous system, belongs the case minutely detailed by Luschka, in Virchow's Archiv, vol.
vi, p. 458. It was an isolated tumor growing in the cerebrum. He describes in it a barred
and trellised stroma ; the growth of villiform, clubbed, and other shaped processes from the
bars of the stroma; their hollowing out by softening, liquefaction, and probable removal of
their axes and central substance. He holds that it is in these hoUowed-out processes that
the blood is contained, only a few having as contents fat granules, cholesterine crystals, lime
salts. But it is not clearly explained how the blood gets into these processes.
504 GENERAL CHARACTERS OF
Such are the principal facts that I can cite regarding the strocture
of the vascular or erectile tumors. They are very meagre, and mach
is left for future inquirers ; especially the manner in which the larger
vessels are connected with those smaller ones which, in most cases,
make up a chief part of the swelling ; and the changes of structure, if
any, which exist in the proper tissues of the walls of the bloodvessel.
Still, from even these few facts some general considerations may be
derived.
That which is common to all the vascular or erectile tumors is an
over-extension of bloodvessels or blood-spaces within a circumscribed
area. The chief varieties depend (1) on the kind of vessels affected,
and (2) on the nature of the tissue in which these vessels lie. The
varieties of the first class have been pointed out ; but all of them alike
present the singular instance of the apparent primary growth of blood-
vessels. In all other tumors, as in all abnormal products, the formation
of bloodvessels appears to be a consequent and subordinate process. As
in the natural development of parts, so in what is morbid, organization
to a certain point precedes vascularity, and the formation of bloodvessels
follows on that of the growths into which they pass. But here the case
appears reversed. The calibre of the bloodvessels increases, and the
solid tissues between them diminish ; all the growth of an erectile tumor
is an enlargement of bloodvessels, with diminution of the tissues in
which they' ramify ; or, rather, it is often an enlargement, not of blood-
vessels, but of blood-spaces : for though, in the first stages of the dis-
ease, the walls of the vessels may grow and elongate, so that the vessels
become tortuous, yet, after a time, the walls waste rather than grow;
apertures seem to form through mutually apposed bloodvessels, and at
length, while the blood within the tumor increases, the bloodvessels
containing it diminish, together with the parts in which they ramified.
Hence, at last, in place of branching and anastomosing tubes, there is
only a network formed of the remains of their walls. This is an increase
of blood-spaces rather than of bloodvessels ; so far as solid tissue is
concerned, we might call it a wasting, rather than a growth ; no new
materials seem to be added, but step by step the bloodvessels are dilated,
and the intervening tissues clear away, leaving room for more and more
blood.
Such a fact constitutes a great contrast between these and any other
diseases named tumors. And yet perhaps we may properly regard
these as being overgrowths of bloodvessels, comparable with the over-
growths of the various other tissues illustrated in the preceding chap-
ters. And their relation to such overgrowths seems, sometimes, dis-
tinctly proved in the gradations of morbid changes that connect them
with mere enlargement of bloodvessels. If we examine different
specimens of these tumors, or sometimes even the condition of the
vessels adjacent to one of them, we may observe a regular gradation
from the erectile tumor, through clusters of dilated and tortuous vessels,
ERECTILE OR VASCULAR TUMORS. 506
to that whieh we regard as merely the yarioose condition of the veins
or arteries. Such transitions are well shown in some of Cruveilhier's
plates, and in a remarkable case by Dr. Hake and Mr. Image ;* as
well as in two of the cases that I have related.
In relation to the tissues in which this overgrowth of bloodvessels
may take place, we may hold that there are two chief classes of cases.
In some the vessels of a natural part are affected ; in others the vessels
of a new growth. In the former class, I think, are the greater part of
the common erectile tumors of the skin, and of the other parts in which
they are most frequently seated ; as the mu8cles,t the bones,| the
orbit,§ and the liver. In these the remains of natural tissues may be
found in the interstices of the bloodvessels, and, either in or near the
tumor, well-known arteries or veins are involved. In the latter class,
examples of which have been cited in the tumors on the side (p. 501)
and on the thigh (p. 502), the bloodvessels of the new-formed parts are
affected. To this class, also, may be referred, I think, the florid and
highly vascular growths that are frequent at the orifice of the female
urethra,!! and perhaps many others.
As I have hitherto chiefly had in view the subcutaneous erectile tu-
mors or n»vi, so I will now, in describing the general characters of the
disease, refer to them alone for examples. Even of these, indeed, it is
difficult to give a general account, since we can make only an artificial
distinction between such as may bear this name, and those extended
dilatations of cutaneous vessels which, with little or no swelling, form
the cutaneous nssvi, port-wine-spots, and the like. These are, evidently,
essentially the same disease ; the terms, cutaneous and subcutaneous
* MediooX!hirurgical Transactions, vol. xxx, p. 109.
t See especially a case by Mr. Liston, Med.-Chir. Trans., zxvi, 120 ; and one by Mr.
Cooce, I. c. ; and Cmveilbier, livr. xix, pi. 5.
X Among these may be included, probably, some of the cases described under the name
of Aneurism of Bone and Osteo-Aneurism ; as by Dr. Handyside, *' Probationary Surgical
EsMy," Breschet, and others. But I am far from convinced that, in all the cases thus en-
titled, the bloodvessels of the bone were primarily or chiefly diseased. My impression is,
that, in many of them, the disease was really medullary cancer of the bone with excessive
development of vessels, and that, in some, it was such a blood-cyst as appears to be some-
times formed in the coarse of a myeloid or cancerous disease.
I From a careful analysis of some twenty recorded cases of pulsating tumor in the orbit.
Dr. Joseph Bell, in an excellent paper in the Edin. Month. Med. Joum., June, 1861, con-
cludes that there is not sufficient evidence for believing that the great majority of these
tnmors belonged to the aneurisms by anastomosis or erectile tumors. Tlie sudden accession
of sjrmptoms which marked the disease in nearly all the cases, and the absence, in those
which were examined after death, of any indications of an aneurism by anastomosis, appear
to him to be conclusive of the disease arising from other causes.
I The specimens of these growths which I have examined have displayed a very abun-
dant and tessellated epithelium covering a small quantity of connective tissue, with close-
set and looped bloodvessels. This account is confirmed generally by M. Verneuil, in the
C. R. de la See. de Biologie, ISS'*), p. 123. But he describes the epithelium as cylindriform.
In a case related by Wedl (Path. Hist., p. 409, Syd. Soc. Tran^l.), it is stated that the rami-
fications of tba vessels precisely resembled those of the vasa vorticose.
33
506 GENERAL CHARACTERS OF
nsevi, respectively applied to them, imply only their difference of seat;
they have no real difference of nature, and are very often associated.
But, if we include only such as are for the most part or wholly sub-
cutaneous, then it may be said that they are generally round or oval,
disk-shaped or spheroidal, but are often ill-defined, the morbid state of
the bloodvessels in which they consist gradually merging into the
healthy state of those beyond them. Sometimes, and especially in those
of most venous character and of longest duration, the mass is circum-
scribed by connective tissue, which forms a kind of capsule, is penetrated
by the bloodvessels passing to and from the tumor, and is very intimately
connected both with the surrounding parts and with the tumor.
The vascular tumors are remarkable by their frequent beginning be-
fore birth, and their especially quick growth in early childhood. Beyond
all comparison they are the most common of congenital tumors. Hence,
mother-spot is almost synonymous with nsevus, and nsevus with erectile
tumor. But they may begin, or accelerate their growth, at any period
of life. I have seen one of which no trace existed till the patient was
25 years old ; and another in which rapid growth began, for the first
time, when the patient was past 50. Dr. Warren mentions a case of
erectile pulsating tumor, about the angles of the eyes and forehead,
which began in a girl 17 years old. Many others, no doubt, have seen
similar cases.
Their origin is generally unknown ; but, as one of the cases I have
related shows, they may commence in the results of injury ; or, rather,
a tumor may originate in injury, and in this tumor an exceeding forma-
tion of bloodvessels may ensue.
Their growth is uncertain ; they may seem at rest for many weeks
after birth, and then grow quickly, and then again may stay their
growth : and, having attained a certain size, may remain therein limited,
or may decrease or disappear, the vessels, in whose enlargement the
growth consisted, regaining their natural calibre or becoming obliterated.
Their maintenance of life, if I may so term it, is not strong. They
are much more apt than the natural tissues are to slough or ulcerate
after injury ; and, in general disturbances of the health, they may perish
altogether. I know of a case in which a large subcutaneous naevus in
a child's forehead sloughed, while another on its back, of much less
size, was in process of sloughing after the application of nitric acid.
Similar apparently spontaneous sloughings have occurred during, or in
the debility following, measles or scarlatina. Such events may be con-
nected with the extreme slowness of the movement of blood in the
tumors ; for though they contain abundant blood, they probably trans-
mit it very slowly. Venous tumors not unfrequently contain clots of
blood and phlebolithes ; such, probably, as would form only where the
circulation is most slow ; and even in the arterial tumors the full pulsa-
tion seems to indicate a retarded stream.
The diseases of the vascular tumors are of much interest ; especially
ERECTILE OR VASCULAR TUMORS. 507
two amongst them, — ^namely, the formation of cysts, and that of malig-
nant structures in their substance.
I just referred to the formation of cysts in erectile tumors, when
speaking, in Lecture XXII, of serous cysts in the neck, and of san-
guineous cysts. The history of the changes by which an erectile tumor
becomes in part or wholly cystic is very incomplete ; for the opportu-
nities of observing them, except when they are accomplished, are rare.
The principal facts are, that, next to the erectile tumors, those that
are composed of clusters of serous or sanguineous cysts appear to be
the most common congenital form, and that in some cases the two forms
appear in one mass. I referred, in Lecture XXII (p. 362), to such a
case as recorded by Mr. Coote. Mr. Caesar Hawkins, "*" also, had before
described similar cases. He says of one, ^^ You may see, in addition to
the usual vessels, that several apparent cells exist. Some of these
were filled with coagulum ; their structure appeared identical with the
other veins, of which they constituted, as it were, aneurismal pouches.
.... There were, however, beside these, some other cysts, which con-
tained only serous fluid, and which were, to all appearance, close-shut
sacs — serous cysts — their size being about that of peas.**
In other instances, no erectile or nsevous structure can be found, but
the communication existing between one or more among a cluster of
eysts and some large bloodvessel, makes it probable that they had the
same origin. Thus, Mr. Coote traced a vein, as large as a radial vein,
opening into the cavity of a cyst, which formed one of a large cluster
removed by Mr. Lawrence from a boy*s side. The mass formed by
these cysts had existed from birth ; some of them contained a serous
fluid, others a more bloody fluid. In another similar cluster,! removed
from a boy's groin, one cyst appeared to communicate with the femoral
vein, or with the saphena at its junction with the femoral. In one case
mentioned by Mr. Hawkins,^ when a cyst in the neck was opened, ar-
terial blood gushed out. In another, the patient died with repeated
hemorrhages from a cyst in the neck, and this cyst was found after
death to be one of several, into some of which the bloodvessels of the
isthmus of the thyroid gland opened.
It is difficult to interpret the formation of such cysts in naevi, or in
connection with them or with veins. It may be, that, as Mr. Hawkins
believes, cysts are formed in these, as they may be in many other tu-
mors, and that gradually, by the absorption produced by mutual pres-
sure, they are opened into communication with one or more of the veins,
or of the sacs connected with th^ veins. Or, as Mr. Coote suggests, it
may be that certain of the dilatations of the vessels are gradually shut
off from the stream of blood, so as to form shut sacs ; and that after
this their contained blood is absorbed, and replaced by serous fluid.
* Medioo-Chirurgica! Transactions^ vol. xxu ; and Medical Gazette, vol. xxxvii, p. 1027.
f The specimen is in the Masuem of St Bartholomew's Hospital.
X Clinical Lectures in the Medical Gazette, vol. xxviii, p. 838.
SRCURBSRT T0M0B8.
Lastly, respecting the production of cancerous disease in I
of erectile tuinora, it seems to be generally regarded as a
event, and these are commonly believed to afford the most freqwnt n»*
stances of malignant growths supervening on such as were preriowdj
innocent. I will not doubt that such events have happened. Ib om
case recorded by Mr. Phillips,* the transition appe%rs to ture beta
very clearly traced. Yet, I think that in many of the cases vbidi
have gained for erectile tumors their ill repute, a oleftrer
would have proved that they were, from the beginning, very
medullary cancers, or else medullary cancers in which blood-c^nt nn
abundantly formed. Or, it may be that the erectile tmnoTV hanWa
presumed to be liable to cancer, through having been auppoaed to bW*
in the peculiar liability of the pigmentary naevi, or moles, to be iW
seats of melanosis.
LECTURE XXIX.
RECURRENT TDM0R8.
In the course of these lectures on tumors, I have pointed oat. mJcr
the head of each class, that, after the complete removal of Diie,iw
growth of a similar nature is likely to recur in the same, or in any otbe
part. And this is certainly the rule for the whole class of inoocfsl
tumors, and a character by which they are seen to be essential! j difer
ent from cancers, amongst which recurrence, after removal, id iW
same, and in other parts, is the rule. 1 have, however, had to tun-
tion, under several of the heads into which the subject has been dividai
instances in which recurrence took place after complete ezlitpalM-
As this is so important a character, and one which posseseee vo md ii-
terest both practically and pathologically, we may fairly be juitifitJii
grouping these tumors under the separate head of Recurrent, and d^
voting a lecture to their consideration.
Almost every form of tumor may occasionally present exampio ^
recurrence, so that the distinguishing term I have employed iuimW
understood to express, not the possession of any specific form or ttrw-
tare, but rather a peculiar tendency manifested in the life of the tOB«-
For it may be accepted as a well-ottablisbed fact, both in fhjmoUfJ
and pathology, that similarity of structure between two or mort difo*
ent parts is not of itself sufHcient to determine functional eccTwf
dence. The examination, therefore, of any texture, either BiariMl ■
healthy, cannot he regarded as complete if it is limited to a bict* ttUt-
mination of its form, appearance, and structure. Ita growth, dffvrbf'
* On VsKulai Tuinon, in the Mediccl Giwue, *ol. lii, p. 10.
RBCURREKT TUMORS. 509
ment, tendencies, influences upon the individual in whom it occurs, in
short, its life, must be attended to. Its teleological as well as its mor-
phological aspects are to be considered.
I haye already described (p. 886) instances in which proliferous cysts
recurred after removal. At p. 457 e. s., several cases have been men-
tioned in which cartilaginous tumors returned not only in the same
part, but even appeared in distant organs. Recurrence and secondary
deposits of the myeloid tumors have now been described in more than
one instance (pp. 471, 510, notes), and the mammary glandular tumors
have occasionally returned after removal (p. 492). The fibro-cellular
tumors, and those growths of mucous tissue already adverted to (p. 415),
also present additional illustrations.
But the form of tumor in which this property of recurrence is most
strongly exemplified, is one which in its structure most nearly resem-
bles that of the common fibrous tumors, and for it I have proposed the
name of " Recurrent Fibroid Tumor."
Although the various instances of recurrent tumors recorded present
many diversities of structure, yet they may be said generally to have pos-
sessed the characters of incomplete development, and to have approxi-
mated to the embryonic or rudimental, rather than the perfect state of
the natural tissues. And this rule of persistent or arrested embryonic
structure in the recurrent tumors is so general, that in practice it is
advisable to speak with hesitation of the ultimate result of any case in
which a tumor is found to be composed of rudimental tissues. This
similarity in structure to embryonic texture becomes more strongly
marked after each removal and recurrence. So that a tumor which, at
first, might be not unlike the normal fibrous or glandular texture in
which it grew, after repeated removal and recurrence becomes softer,
more succulent, and in its later growths may seem to the naked eye
little more than like masses of yellow or ruddy soft gelatine with blood-
vessels.* The later are usually much more rapid in their progress than
the earlier growths : they are generally less well defined, penetrating
farther and more vaguely among the interstices of adjacent parts, and
more quickly protruding through the skin or scars over them.
And in these characters the later-formed tumors assume more of the
character of malignancy than the earlier. In the case I relate on p.
511, the last tumor was, in general aspect, hardly to be distinguished
from brain-like tumor, though in microscopic characters essentially
like its predecessors. In one of Professor Gluge's cases the transitions
to completely malignant characters appeared yet more sure. Mr. Syme
also expresses a similar transition : describing, as the usual course of
the cases he has seen, that after one or two recurrences of the tumor,
the next new productions present a degeneration of character, excite
* An exoellent illastration of this change from the normal type of the texture to a more
mdimental form, is presented by the case of cylindroma recorded by Busch and Billroth.
Note, p. 4] 5.
510 REOUBBENT TUMOBS.
pain, proceed to fungous ulceration, and thus in the end prove fatal.
So that, although there be cases in which this evil career has not been
run, yet I think we may regard these tumors as approximating to
characters of maligniincy, not only in their proneness to recurrence
after removal, but in their aptness to assume more malignant features
the more often they recur. Whatever be the truth concerning the sup-
posed transformation of an innocent into a malignant morbid growth, I
think it can hardly be doubted that in the cases of some recurring tumors
the successively later growths acquire more and more of the characters
of thoroughly malignant disease.*
But this evil result does not by any means follow as a necessary con-
sequence of the repeated recurrence of the tumor, for there are many
cases now recorded in which the patient retains, to all appearances,
perfectly good health, and shows none of that cachexia which would
almost certainly exist in a patient who had suffered repeated recurrences
of cancer. No more striking example could be adduced in illustration
than the case related by Dr. Douglas Maclagan, and described farther
on, in which the tumor appeared upwards of thirty years ago, recurred,
and was removed three times, with considerable intervals between each
recurrence, and yet the patient is still in perfect health.
The recurrence of these tumors takes place, not merely in the same
organ or tissue, but in loco — ^in the place in which they originally
occurred — in the cicatrix, or closely adjacent to the scar of the first
operation wound. And here, again, do they possess a character by
which they are distinguished from the malignant tumors, which in their
recurrence may multiply not only in the same part but in distant organs.
Cases certainly have been recorded, more especially of some cartilagin-
ous tumors (note, p. 458), in which growths of the same nature arose in
distant parts, as the lungs, but in them there is distinct evidence of the
growth being propagated along the lymphatics into the veins, and then
into the pulmonary artery and its minute branches.f
Thus we have in these recurrent tumors characters which connect
them on the one hand with the innocent, and on the other with the ma-
lignant tumors, so that the plan I have adopted of placing them in a
group intermediate between those two great divisions seems not inex-
pedient. And this relation to, and partial possession of, the characters
* An illustration is presented by a remarkable case, of which specimens are described in
Cat. Mus. St. Bartholomew's, Ser. xxxv, Nos. 28, 29. Other examples are adduced in the
recurring proliferous cysts, p. 387, and in a case of recurring fibroid recorded by Mr. Hulke,
Med. Times and Gazette, Nov. 29, 1862.
t Dr. Wilks also has recorded a case (Path. Trans., vol. x, p. 244) of a man whose leg
was amputated by Mr. Cock, for a large myeloid tumor of the head of the fibula. Two years
aAerwards a recurrence took place in the stump. Removal was again performed, and t
few days afterwards the man died of pleurisy. At the post-mortem examination, secondary
myeloid tumors, of considerable size, were hanging pendulous from the exterior of the lungs,
but not infiltrating their substance. But the more frequent result of amputations for recurrent
tumors of the limbs, has been an apparently final remedy.
BBCUBRIKG FIBROID TUMOBS. 511
common to the two diyisions, appears to be in some measure accomited
for by these' recarrent tumors being so frequently found in members of
cancerous families. I have seen several cases in which these tumors
occurred in the descendants or near relatives of those who are, or have
been, cancerous, and I have heard and read of others like them ; from
which I have been led to form the opinion, that, amongst the members
of families in which -cancer has manifested itself, there is a peculiar
liability to the production of tumors, which will recur after repeated
and complete excisions, though they are neither cancerous in structure,
nor attended with similar disease in the lymphatic or other organs ; nor
with any cachexia but such as may be ascribed to their gradual influ-
ence upon the constitution.*
With these general remarks on the group of recurrent tumors, I shall
now proceed to a more detailed account of those which I have termed
Recurrent Fibroid, and among which, although the general characters
of the group are equally well marked among those of other rudimental
structures, the most striking examples have been found.
A brief account of some cases of this tumor may best illustrate it.
The first I saw was from a gentleman, 60 years old, under the care
of Mr. Stanley. In 1846 a tumor was removed by Mr. Cockle from
the upper and outer part of his leg. It lay close to the tibia, was as
large as a filbert, and was considered fibrous. Some months afterwards
another tumor was found in the same place, and, when as large as a
walnut, was removed by Mr. Hamilton, of the London Hospital, who con-
sidered it " decidedly fibrous." In October, 1847, Mr. Stanley removed
from the same place a third tumor ; and this I examined minutely. It
had the shape, and nearlv the size, of a patella, and the note that I made
of its general appearance was, that it was '^ very like those fibrous tumors
which are whitest, most homogeneous, and least fasciculate and glis-
tening;" and that *' with-
out the microscope I should ^^S- 79.t
certainly have called it a
fibrous tumor."
The microscopic exami-
nation, however, showed
peculiar structures (Fig. \ i jj ^ ^ ^
79). The tumor was com-
posed almost entirely of
very narrow, elongated,
caudate, and oat-shaped
nucleated cells, many of which had long and subdivided terminal pro-
cesses. Their contents were dimly shaded ; and in many instances the
* For a more detailed account of the relations of recurrent to cancerous tumors, I may
refer to a paper in the Medical Times and Gazette, August 22, 1S57.
f Fig. 79, microscopic elements of a recurring fibroid tumor described above. JNIagni-
fled about 400 times.
612 RECURBIKG FIBROID TUMORS.
nuclei appeared to swell out the body of the cell, as in the most elongated
granulation-cells. With these cells were scattered free nuclei, and gm-
mous or granular matter, such as might have been derived from dis>
integrated cells. Very little filamentous tissue was contained in any
part of the tumor.
Now, in the extirpation of the third tumor, the parts around it were
very freely removed, the periosteum was scraped from the tibia, and
every assurance seemed to exist that the whole disease was cleared away.
But, in June, 1848^ two small tumors appeared in the subcutaneous
tissue just below the seats of the former operations. These also were
removed, and these had the same fibrous appearance, and the same mi-
nute texture, as the preceding. Some months only elapsed before in
the same place another tumor grew ; t. e. a sixth tumor. The patient,
despairing of remedy by operations, allowed this to grow till Novem-
ber, 1850, by which time it had acquired a diameter of between four
and five inches, and protruded as a large soft fungoid mass from the
front of the leg. Two profuse hemorrhages occurred from it, and
made him earnestly beg that his limb might be removed to relieve him
from the extreme misery of his disease. The amputation was per-
formed, and he died in a few days.
The tumor* appeared confused with the thin skin over it. It rested
below on the muscles of the leg, but was not mixed with them, except at
a scar from the former operations. The tumor was milk-white, soft,
and brain-like, except where discolored by effused blood, and in the ex-
posed parts was soft, pulpy, and grumous. One would certainly, judg-
ing by its general aspect, have called this a brain-like medullary can-
cer ; and yet it had essentially the same microscopic characters as the
tumors I first examined from the same patient : only, the narrow, elon-
gated, caudate cells were very generally filled with minute shining
molecules, as if from fatty degeneration connected with the protrusion
and partial sloughing of the mass. Unfortunately, no examination of
the body was made after death, and it could only be guessed, from the
absence of emaciation, and of all other indication of general loss of
health, that no similar disease existed in internal organs.
In another case of the same kind, I assisted Mr. Stanley, in May,
1848, in the removal of a tumor from the shoulder of a gentleman
twenty-eight years old. It had been growing under the deltoid for six
months, was loosely connected with the surrounding parts, and was
about three inches in diameter. It had the general aspect of a com-
mon fibrous tumor : firm, tough, white, traversed with irregular bands.
It yras easily and complely removed, but was not examined with the
microscope. The wound of the operation healed well ; but, two months
afterwards, a second tumor appeared under the cicatrix. This was re-
moved with some of the adjacent muscles, and other tissues. It was
* In the Museum of St Bartholomew's.
RBOUBRIKG FIBROID TUMORS. 518
like the first, only less tough, and more lobed, and elastic ; bnt under
the microscope, instead of appearing fibrous, it was found to be com-
posed almost entirely of elongated and caudate nucleated cells, very
like those described in the last case, and mixed with free nuclei and
granular matter.
In March, 1849, a third tumor was removed from the same part,
which had been noticed two months, and again presented the same
character ; it was indeed grayer, and less firm, and more shining and
sncculent on its cut surfaces, but the differences to the naked eye were
not great, and the microscopic structure was the very same as in the
former instance.
In October, 1849, another tumor had formed, and, after it had re-
sisted various methods of treatment, Mr. Stanley removed it, by a fourth
operation, in December. This had again the same character.
In the course of 1850, a fifth tumor appeared in the same part, and
this, after growing slowly for an uncertain time, ceased to increase, and
has now been for a long time stationary, without in any way interfer-
ing with the patient's health. He is pursuing an active occupation,
and, but for the tumor, might be thought a healthy man.
In a third case, Mr. Syme removed, in 1839, a tumor which, without
any known cause, had been growing for a year, over the anterior part
of the first right rib of a gentleman 48 years old. Two years after the
operation, another tumor appeared in or near the same part, and was
removed by Mr. Syme in 1843. A third was removed by him in 1847 ;
and a fourth in 1849. After another distinct interval of apparent
health, a fifth tumor appeared, and grew quickly, and was removed by
the same gentleman in 1851. In one of these, an account of which was
published by Mr. Syme, Dr. Hughes Bennett found microscopic struc-
tures similar to those of the fibro-plastic tumors of Lebert ;* similar,
therefore, I have no doubt, to those described above. The patient re-
covered from the last operation, as from all the previous ones, quickly
and favorably ; but the wound had scarcely healed when two more tu-
mors appeared beneath the scar, like the preceding ones, except in that
they grew more rapidly.
One of these tumors was so firmly fixed at the clavicle that no further
operation could be recommended. In six months' growth the tumors,
at first distinct, had formed a single mass, deeply lobed, of oval form,
measuring a foot in one direction, and about ten inches in the other.
It covered, and felt as if tightly fixed to, the middle half of the clavicle,
and thence extended downwards over the chest, and outwards towards
the axilla. It felt heavy, firm, tense, and elastic. The skin, thinly
stretched over it, and by its tension appearing as if adherent, was gene-
rally florid, but in some parts livid, and over the faiost prominent lobes
♦ Monthly Journal of Medical Science, vol. ^, p. 194. Probably this refers to the elon-
gated ceUs alone. I have not, in any' of these tumors, found the large many-nucleated cells
which occur in most of the tumors named fibro-plastic by M. Lebert
514
RBCURBIKG FIBROID TUMORS.
ulcerated ; but the principal ulcers were superficial, covered with healthy-
looking granulations, discharging thick pus, having no cancerous or other
specific character : only one of them had a thin slough. Such were the
characters of the disease when I saw it in February, 1852, and it was
very striking, as evincing one of the contrasts between this form of
tumor and any rapidly-growing ulcerated cancer, that the patient's
general health was scarcely affected. He was still a fiorid, sturdy man;
and he fed, slept, talked, and moved about as a man in health might do.
He suffered scarcely any pain ; but, within the last month, the ulcerated
surface of the tumor had bled severely. The tumor was now submitted
to compression, with Dr. Neil Arnott's apparatus ; and with some ad-
vantage, inasmuch as its growth was retarded, and the hemorrhage was
prevented, so long as the pressure was maintained. Twice, however,
on the instant of removing the apparatus, I saw arteries as large as the
radial throw blood in a jet far from the trunk. The bleeding was in
this respect such as I have never seen from the proper vessels of any
other tumor, and was like that described as occurring in the first of
these cases.
It would be useless to tell, at any length, the later history of this
case. The tumor increased constantly to the time of the patient's
death in July, 1852 ; but, in the last two months, several small portions
of it sloughed away, and it gradually shifted lower down on the chest,
leaving the clavicular region, so that at the time of death it lay movable
on the muscles, and could be removed, ''as a common fatty tumor might
be," without dividing any important part : death seemed due to mere
exhaustion, consequent on the discharge from the tumor, and the pain
to which, as it extended farther into the axilla, it gave rise. Dr. Ross,
to whom I am indebted for an account of the conclusion of the case,
Fig. 80.*
could find no indication of disease in any internal organ. Only the
tumor was allowed to be examined after death ; and Dr. Ross wrote to
me of it, in addition to the account of the absence of any deep connec-
tion or infiltration of adjacent tissues, that " its texture was pretty
* Fig. 80, microscopic structures of the recurring fibroid tumor described above. Mag-
nified 450 times.
RBOUBBINa FIBROID TUMORS. 615
hard, like that of a fibrous tumor, but not nearly so dense or crisp as
scirrhus. It scarcely gave out any blood on being cut into; but here
and there was to be seen, on the surface of a section, the open mouth
of a vessel, just as in a section of liver. All the textures behind, form-
ing the bed of the tumor, appeared quite healthy."
A portion of the tumor, kindly sent to me by Dr. Ross, was, after
having lain in spirit, milk-white, firm, elastic, of very close texture,
breaking and tearing with a coarse fibrous grain. It had, most nearly,
the aspect of a very firm fibro-cellular tumor altered by spirit. When
scraped it yielded little or no fluid, but white shreds, in which, together
with much that looked like withered tissue or d6bris, there were abun-
dant slender awn-shaped corpuscles, such as are sketched in Fig. 80.
They looked dry and shrivelled, containing no distinct nuclei, but mi-
nute shining particles, as if themselves were outgrown nuclei. With
these, also, were numerous broader and shorter corpuscles, of the same
general aspect, but inclosing oval nuclei ; and yet more numerous
smaller bodies, like shrivelled, oval, elongated, free nuclei, dotted, and
containing minute shining particles. The whole mass appeared made
up of corpuscles of these various shapes, irregularly or lineally im-
bedded in a substance that was nearly structureless or imperfectly
fibrillated. Only in a few places, perhaps in the partitions of the lobes,
there was a very small quantity of fine connective tissue.
I think there can be no doubt that this case was essentially of the
same kind as the former two ; and the constancy of their peculiarities
in both history and structure appears sufficient to justify the placing
them in a separate group and under a separate title. But these are
not the only cases to be cited.
Professor Gluge has given a good general account of the history of
such tumors as these, as examples of the forms transitional to cancer.
He names them " albuminous sarcoma ;" a term one hears frequently
used, without, perhaps, any clear meaning ; yet generally, I think, with
the suspicion that the growths to which it is applied are not wholly
innocent. Among the cases which he cites, one coincides exactly with
those I have detailed. A major, 45 years old, fell from his horse, in
1843. Six or seven weeks afterwards, a tumor appeared over his
scapula. It was removed, but after some months returned. Between
1843 and 1848, four such tumors were removed from the same part.
In 1848, the patient was under the care of M. Seutin, who removed the
fifth tumor ; and Gluge's description of this, including the expression
that in color and consistence it was like the muscular tissue of the in-
testinal canal, leaves little doubt that it was like the less firm of the
specimens that I have been describing. In the last of these five opera-
tions, and in one previously, the removal of the tumor was followed by
firee cauterization of the wound ; yet the last account published by
Professor Gluge was, that in April, 1849, a sixth tumor had appeared
516 RECUBRINa FIBROID TUMORS.
in the same part ; and he has informed me by letter that in 1850 the
patient died.
Lastly, a case which, in its conclusion, is the most instructive of all
that have been recorded, is related by Dr. Douglas Maclagan.*
A girl, 22 years old, had a tumor, of three years' growth, on the left
lumbar region, about an inch from the spine. In 1882, it was about as
large as a Jargonelle pear, firm, but elastic and movable, and below it
was a portion of indurated skin. The tumor and diseaised skin were
removed, and the former '^ possessed most of the characters of a simple
fibrous tumor." After about twelve months the disease returned in the
scar. Three little tumors formed, and these, with the scar, were re-
moved freely, in February, 1834. "The extirpated mass bore a
striking resemblance to that previously removed." Between twelve
and eighteen months later, a third growth appeared, which, after in-
creasing for a year and a half, was removed. " It had the same elastic
feel and fibrous appearance ; and the semi-transparent pinkish gray
color was the same as in the original tumor." In March, 1857, Dr.
Maclagan sent me a portion of another tumor cut out from the same
place in this patient, by Mr. Spence. " The specimen presented to the
naked eye exactly the same appearance which the former tumors did."
On microscopic examination it was exactly after the type of the recur-
rent fibroid tumors, and in naked-eye appearance just like the others
that I have seen. Dr. Maclagan kindly writes me, " that at the pre-
sent time (November, 1862, thirty years after the removal of the first
tumor) she is in perfect health, and daily follows her avocation as i
laundress. Since 1857 there has been no further recurrence of the
tumor."
Dr. Maclagan has added the account of another case, in which the
essential features were quite similar ; and another, which I believe must
be referred to this group, is accurately described and figured by Dr.
Hughes Bennett. t
During the past ten years the literature of these recurring fibroid
tumors has received considerable additions by the publication in various
quarters of numerous cases which have fallen under the notice of differ-
ent surgeons. To some of these it may be convenient to give the re-
ferences. Mr. Birkett in Guy*s Hospital Reports, Ser. iii, vol. i?;
Mr. Hutchinson, Med. T. and Gaz., August 20, 1853 ; Billroth, Vir-
chow's Archiv, B. viii, 1855; Verneuial, Mem. de la Soc. de Biologic,
1855 ; Mr. Callender, Trans. Path. Soc, vol. ix, p. 327 ; Dr. Roberts,
Beale's Archives, October, 1861 ; Mr. Annandale, Edin. Med. J»L,
p. 432, 1862 ; Mr. C. Heath and Mr. Hulke, Med. T. and Gaz., Not.
18, 1862.
* Edinburgh Medicnl and Surgical Journal, vol. zlviii, 1837.
■f On Cancerous and Cancroid Growths, p. 87
FIBRO-NUCLEATED TUMORS. 517
FlBRO-NUOLEATED TUMORS.
Dr. Hughes Bennett"^ has given the name of Fibro-nuchated to cer-
tain tumors, first described by himself, of which I think that future
investigations vrill prove a very near affinity with those which I have
been considering. They are, indeed, of so rare occurrence, that we
cannot as yet be sure of many things concerning them ; but their most
usual characters seem to be, as assigned by Dr. Bennett, a general re-
semblance to the fibrous tumoi;^ ; a tendency to return in the part from
which one has been excised ; an absence of disposition to affect lym-
phatics or more distant parts ; and a texture '^ consisting of filaments
infiltrated with oval nuclei." The first three characters are repetitions
of those belonging to the recurring fibroid tumors ; the last is not so ;
and yet the difference of structure is such as may consist of a very near
natural relationship. For, as we have seen, both cells tending to elon-
gate and attenuate themselves into filaments, and nuclei imbedded in a
simple or filamentous blastema, are equally forms through which fibro-
cellular or fibrous tissue may be developed (see p. 140, &c.). And
thus it may be that, in these two groups of tumors, the similarly con-
trasted forms of elemental structure may be nearly related, in that both
alike represent persistently imperfect developments of fibrous masses.
However this may be, the history of these cases is important, espe-
cially because, like the last described, they seem to occupy a kind of
middle ground between innocent and malignant tumors. They are
among the diseases which are often spoken of as '^ semi-malignant,"
'Hocally malignant," or 'Mess malignant than cancer:" terms which
are generally used in relation to what are deemed exceptional cases,
but which may appear to have a real meaning if ever we can apply
them to well-defined groups of tumors.
The most characteristic of the cases described by Dr. Hughes Ben-
nett, was that of a lady 25 years old, from whom, when she was 18, a
tnmor of four years' growth was removed from the left thigh, nearly in
front of the great trochanter. After its removal there remained a small
hard knot in the scar ; but no change ensued in this for six years.
Then it began to enlarge and increase, and in a year increased to the
sixe of a small almond-nut. It was superficial, quite movable, and in-
timately adherent to the skin. It was hard and dense ; and its cut
surface was smooth, slightly yellowish, and yielded no juice on pressure.
It appeared to consist of fine filaments, among which oval bodies, like
nuclei with nucleoli, were everywhere infiltrated. Here and there large
oval rings appeared, marked by converging irregular lines, and, in a
few places, oval spaces surrounded with concentric marks, like sections
of gland-ducts.
The only well-marked case that I have yet seen was that of a boy,
10 years old, on the palmar aspect of whose fore-arm a small indenta-
tion was noticed at birth. This part was slightly wounded when he
* On Cancerous and Cancroid Growthti p. 176, &c.
618 FIBBO-NDOLEATED TUH0B8.
was two years old, and from that time a tumor began to grow. When
he was four, the tumor wae removed (of course complet«ly) by Mr.
Sande Cox, but the wound did not heal before another growth appeared.
This increased at first slowly, but at last quickly ; and when the boy
came under my care, it formed an oval swelling rising to nearly an inch
and a half above the surrounding skin, and measuring from three to
three and a half inches in its diameters. The skin over it was very
thin, adherent, tense, and florid, aiid at the centre ulcerated, and super-
ficially scabbed ; the ulcerated surface was granulated, like one slowly
healing. The mass felt firm and elastic, and, at its borders, very tough,
like the tissue of a cicatrix ; little cord-like branching processes ex-
tended from its borders outwards in the deeper substance of the cutjs ;
and above the principal mass another, like a small flattened induration
of the skin, was felt. The growth was not painful, and the general
health appeared good. Some axillary glands were slightly enlarged.
I removed the whole disease, with all the surrounding skin that ap-
peared in any way unhealthy, and large portions of the fascia of the
fore-arm and of the intermuscular septa, to which the base of the growth
adhered intimately, and which were indurated and thickened. The
wound very slowly healed ; the enlargement of the axillary glands sub-
sided ; and the patient remains well to this time, twelve years since the
operation.
The tumor was intimately adherent to all the parts adjacent to it,
yet was distinct and separable from them. Its section was smooth and
shining, of stone-gray color, shaded with yellowish tints. It was lohed ;
but in its several lobes was uniform, and with no appearance of fibrous
or other structure ; but intersected irregularly by white and buff-yellow
branching lines, where the microscope found a fatty degeneration of tbe
tissue. Id texture the tumor was firm, but easily breaking and split-
ting in layers, shell-like: with the microscope it appeared to be com-
posed of two materials; namely, nuclei, and a sparing granular or
molecular substance, in which they were imbedded. These, as Bketched
in Fig. 81, were so like those re-
Fig- 81.* presented by Dr. Bennett, as to
leave little doubt of tbe similarity
of the two cases ; only there WM
here less appearance of fibrous
structure, and less of texture like
that of the glands. The nuclei
were, generally, of regular elon-
gated oval shape, from tkiid^ ^
jjooth of an inch in length, auil
generally bi-nucleolated ; compa-
ratively few were broader, or reni-
« or ihe tumor described above. A, mignilad
80IRBH0US OR HARD CANCER. 519
form, or irregular. They were very thickset in a molecular hasis-suh-
Stance, and in many parts (perhaps in all that were not disturbed) they
appeared as if arranged in overlaying double or triple rows, which
radiated to a distance from some point, or from some space of round or
elongated oval form. These spaces, if they were such, appeared full of
molecular matter.
It would be wrong to endeavor to draw many conclusions from so
small experience as yet exists on these tumors. I will only -express or
repeat my belief (which fully concurs with what Dr. Bennett has stated)
that these are examples of a form of tumor different from any others
yet classified ; and that they will be found most nearly related to the
recurring fibroid tumors.
LECTURE XXX.
SCIRRHOUS OR HARD CANCER.
PART I. — ANATOMY.
Thb foregoing lectures on tumors have comprised the histories of the
Ihnocbiit and the Rbourrbnt Tumors ; and in the first of them I re-
lated the characters generally appertaining to the Malionant Tumors,
or Cancbrs, which it now remains to describe.
For an account of this class of tumors it will, I hope, suffice if, after
reference to the first of these lectures, I describe, in order, each of the
chief forms in which cancers occur, and then gather such conclusions
as may be drawn respecting the general pathology of the whole class,
and the relations of the several forms to each other, and to other
tumors.
The chief forms of cancer are named severally Scirrhous, Medullary,
Epithelial, Colloid, Osteoid, Melanotic, Villous, and Hsematoid. These,
at least, are the names most frequently applied to them. The degrees
of difference between the diseases to which they are severally applied
are not nearly equal ; and, probably, under certain of them, two or more
diseases are included which are sufficiently different to justify their
separation with distinct names. But these are points which, having just
mentioned, I may leave to be discussed in the account of each form of
cancer, or in the concluding lectures.
First, I will speak of Scirrhous or Hard Cancer.
Being both more frequent and more obvious than any other form of
cancer, this was, to the beginning of the present century, the type and
chief example of the disease ; and so, in regard to its physiology, and
many particulars of its structure, it may still remain. It has received
520 HARD CANCER OF THE BREAST.
many names,* such as scirrhus, scirrhoma, and others, expressing that
hardness of texture which is its distinctive and especial character-
istic ; or such as Carcinoma reticulare, implying certain minute peea-
liarities of structure. I believe, however, that these peculiarities are
too inconstant and accidental to justify the division that they suggest:
I will therefore include them all under the name of Scirrhous or Hard
Cancer ; and will use these terms for all stages of the disease, avoiding
that which seems always a confusing distinction in which, before ulcer-
ation, the disease is called Scirrhus, and after it, Cancer.
I will describe the Scirrhous Cancer, first, as it occurs in the breast,
because here the disease is far more frequent than in any other part,
and presents, openly, most of its varieties of appearance according to
its successive stages, and the accidents to which it is exposed.
The scirrhous or hard cancers in the breast are very far from being
so uniform that they may be briefly described. I believe that they are
always primary cancers; always infiltrations; and almost always
seated, in the first instance, in some part of the mammary gland; but,
when we compare their other characters in any large number of speci-
mens, we find in them many and great diversities. Probably, therefore,
it will be best if I describe first and chiefly the ordinary characters of
the disease ; the form in which it is most frequently seen, when it his
not been changed by softening, ulceration, or any other morbid prooesa
I can then add to this description, by way of comparison, some accomits
of the principal deviations from the more usual form ; and, in the next
part of the lecture, can give the history of the changes that ensue in
the progress of hard cancers towards destruction, or in their much rarer
regress.
Most frequently, the scirrhous cancer of the breast appears as a hard
mass occupying the place of the mammary gland, or of some portico of
it. In the cases I have collected it has not been more frequent in one
breast than in the other. It is least frequent at or near the inner
margin of the mammary gland ; but with this reservation, it is not
more frequent in one than in another part of the gland, or in any part
than in the whole.
While part of the gland is cancerous, the rest is, commonly, healthj;
but, according to the age and condition of the patient, it may be more
or less atrophied and withered ; or excess of fat may be accumolatad
around it ; or it may contain numerous small cysts, or one or more
large cysts, most confusing to the diagnosis ; or, more rarely, it may
be the seat of mammary glandular tumor (p. 491), or of some morW
change of structure. As yet, however, I believe, no connection can be
traced between any of these conditions and the growth of cancer, lO*
* Enumerated by Dr. Walshe : On Cancer, p. 10.
BABI> OAROBB OF THB BBEABT. 521
less it be that it is peculiarly apt to happen in breaets that are being
defectively nourished.
The hardness of the cancer, as compared with that of other tumors,
is in most cases extreme : it ie about equal to that of a lump of fibrous
cartilage, and is associated with a corresponding rigidity, weight, and
inelasticity. Gases, however, are not uufreqaent, especially when the
cancer grows quickly, in which the maas is less hard, — very firm rather
than hard, — about as flexible and elastic as the body of an nnimpreg-
nated uterus.
The sise of a hard cancer is seldom very great. In most cases, it is
rather smaller than the part of the gland which it occupies was in the
healthy state ; so that, e. g., if half a mammary gland become cancer-
ous, and half remain healthy, the latter may be two or three times
larger than the former ; or, if the whole gland become cancerous, it
may be reduced to less than half its natural size. The exceptions to
this diminution in the size of the cancerous gland are, I believe, in cases
of very rapid growth, in which the cancer-materiaJ seems to be added
more rapidly than the materials of the gland can be removed.
The shape of the hard cancer, also, depends chiefly on the part of the
gland that it affects. Generally, it may be said that when the cancer
does not extend beyond the limits of the gland, it does not much deviate
from the shape of the affected part ; only, it gathers up, as it were, the
gland-lobes into an irregular lump, in which their outline is not lost,
but blunted. Hence, according to their seats, we may observe different
shapes of hard cancers of the breast. At the anterior surface of the
gland it is nsn^ly convex or obliquely shelving ; at the posterior sur-
face it is flat or slightly concave, resting on the pector^ muscle ; in
the middle, or thick sub- _ g. ,
stance, of the gland it is
oommonly rounded and
eoaraely tuberous, knot-
ted, or branched ; at the
borders it is often discoid,
or else is pecnliarly apt to
«ztend from them in a
mass reaching to the ad-
. jacentskin (Fig. 82) ; and
when the whole gland is
affected, the cancer has commonly a low conical shape, or is limpet-
ihsped, with tbe nipple set on the top of the cone (Fig. 88).t
* Fig. 83. Section of ■ hard cincei, eiiendiDg l>Otn a border-lobe of the mammiiry
gl*Dd to (he nperjacent akin, and aSecling both iheae anil lbs intervening liwuec Nnlii-
\ The leima " ninioae,'' " tuberoui," and " inlillTHled," hare been applied 1o ipeciry [he
bard caDcrn, according ta their ihapea ; but at preienl tbe sbape appears so lillle connecieil
wilh maj other character of the diMaae, — it seemi lO nearljr accidental,— that it cannot well
522 AHATOMT or SOIRBHOTTB OASOBK OV THB BBIA8T.
From Koy such cancerous lump, processes, like crooked, gnarled,
and knotted branches, may extend outwards in correspondence witb
the outlTing lobes or processes of the gland. But shapes like these are
comparatively rare ; and
^'s- 88.» scarcely less ao are the
instances in which poi^
tions of the gland, after
becomiDg cancerous, are
detached from the chief
masB ; or those in which,
in the same gland, more
than one cancer ftnrms at
the same time. Such cases do, however, happen; and I hare known
the smaller detached cancers nearly escape removal in operations.
As we dissect towards the surface of a hard cancer, especially of one
of which the growth is not very rapid, we may observe that relation of
the tissues around it which is so characteristic : I mean, their contrac-
tion towards it, and their progressive absorption. It is as if, in its pro-
gress, the cancer were always growing and more dense, by the contraction
and compacting of its substance, and by the absorption of the tissnee it
involves ; and as if, in this concentric contraction, it drew all psrta
towards itself. To this it is due, that, even from the first, and when
it is yet very small, a hard cancer in the breast feels as if it could only
be moved with the gland around it ; it does not slide or roll nnder ti*
finger as a mammary glandular tumor does. To this, also, is due the
slight dimpling of the skin overfthe nearest adjacent part of the can-
cer, even long before the two have become adherent ; and to this we
must ascribe the more numerous depressions, seaming and wrinkling
the surface of the breast, and making it appear lobed, when, in a case
of cancer occupying the whole of a large and fat breast, many parts of
the skin are drawn inwards. To the continuance of this contraction
and absorption, also, are due the sinking down of the retracted nipple,
and the uplifting of the superficial fibres of the great pectoral muscle;
and then, the deeper furrowing and the adhesion of the sunken skin or
nipple, and the firm conjunction of the pectoral muscle with the deepest
portion of the cancer.
Sometimes one finds bands of tough tissue extending from the re-
tracted parts of the skin to the surface of the cancer. These are com-
monly supposed to be always cancerous, — " claws," or outrunners from
the cancer ; but the supposition is only sometimes true ; they often con-
sist of only the connective tissue between the lobes of the subcutaneoiu
fat, condensed and hardened,
l>e ndopted for a ground of specific appellniion. Moreover, there is no renKiii for e»ped»l!f
calling Ihe cancerB thai aflecl Ibe whole f^land, infilirBled ; Tor ail the hard caneen it iba
bteaat are inflllraiions in less oi more of ils Biruciure,
* Fig. B3. Seclion of ■ hard cancer or a whole mammary gland. Half (ha nauual hm
CONDITION OF THE TISSUES INVOLVEI). 528
A Boiirhous cancer in the breast has no distinct or separable capsule
of conneotive tissue investing it : the proper tissues of the breast, that
•re in contact ivith its surface, adhere to it very intimately ; and the
more so, the more slowly it has grown. The general boundary be-
tween them is, indeed, distinct to the sight ; yet it is not easy to dis-
sect out the cancer ; and, at certain parts, it is evident that the tissues
around the cancer are continuous with some of those within it. Espe*
dally, we can often see that the lactiferous ducts pass, from the nipple,
or some healthy portion of the gland, right into the substance of the
cancer.
When we cut through an ordinary hard cancer of the breast, such as
I am chiefly describing, the surface of the section becomes at once, or
in a few minutes, slightly concave. This is a very characteristic ap-
pearance, though not a constant one : I know no other tumor that pre-
sents it. In all others, I think, the sarface of the section either rises,
and becomes slightly convex, especially at its borders, or remains ex-
actly level. In well-marked hard cancer, the cut surface becomes con-
cave, sinking in towards its centre, through the persistence, I suppose,
of that tendency to contraction, to which, during life, we have to ascribe
the traction of the surrounding tissues, and which is now no longer re-
sisted by them.
The cancer seldom appears, on its cut surface, divided into lobes : it
is one mass, variously marked, perhaps, but not partitioned ; neither
has it any distinct grain or fibrous plan of structure ; its toughness and
tenacity are complete, and in every direction equal. It has, generally,
a pale grayish color, and is glossy, and half translucent ; often it is
slightly tinged with a dim purple hue, or, in acute cases, may be more
deeply and more darkly suffused. Very often, too, its grayish basis is
marked with brighter whitish lines, like interlacing bundles of short
straight fibres, and with minuter ochre-yellow lines, or small yellow
spots, and with various transverse and oblique sections of ducts.
The explanation of these various appearances, and of the minuter
characters of the cancer, can be understood only by recollecting (what
all the foregoing description will have implied), that the cancerous mass
is composed not only of structures proper to the cancer, but of more or
less of the tissues of the mammary gland, or other parts, among which
tbe cancer-structures are inserted. And the differences implied in the
words ^^ore or less," may be considered as explaining many of the
differences of appearances that hard cancers present.
The consideration of the influence of cancer-formations on the tis-
sues that they occupy belongs, more properly, to the general patho-
logy of the disease ; but I must here just refer to the main facts concern-
ing it.
As I have said, the formation of a scirrhous cancer of the breast con-
sists in the production of peculiar structures — cancer-cells and others —
in the interstices of the proper tissue of the part (see Fig. 84, p. 525).
524 ANATOMY OF SCIRRHOUS OR HARD CANCBR.
Yirchow'*' has fairly likened it, so far as the relation of the new and old
materials is concerned, to the condition of pneumonia in a lobule of the
lung, in which the lymph is situated among the natural textures, so as
to be thoroughly mixed up with them, and to form one mass with them.
Thus, then, we have, in any such cancer of the breast, a mixture of
cancer-substance and breast-substance. But among many cancers we
should find many diversities in the proportions of these two substances,
which diversities are determined, first, by the original proportions in
which the two substances are mingled ; and, secondly, by the degrees of
wasting, and. other changes, that may occur in either or both of them.
For example, a large quantity of cancer-substance may occupy so small a
portion of the gland, that this portion, spread out as it is in the substance
of the cancer, may be scarcely discernible, and the cancer may look like
a completely isolated tumor ; or, on the other hand, the whole of an atro-
phied gland may be condensed within a comparatively small cancer.
Moreover, after the original proportions of the two substances are
determined, they may not remain the same ; for their subsequent pro-
portions of increase or of decrease may be different. Grenerally, as the
cancer-substance increases, so the involved structures of the breast
diminish or become degenerate, till they can hardly be recognized, and
the cancer is where the natural structure was : a complete *^ substitii-
tion," as M. Lebert names it, is thus accomplished. But the original
tissues do not thus disappear at any given rate, or all in the same rate
or order. The gland-lobules, I think, waste very early : I have never
found them clearly marked within a hard cancer. The larger gland-
ducts remain much longer ; their cut orifices may be often seen on the
section of the cancer, or they may be traced right into it from the nip-
ple, or fragments of them may be found in microscopic examinations.
The small gland-ducts, with their contents, often appear, in branching
bufi* and yellow-ochre lines, imbedded in the substance of the cancer.
The fat of the breast is commonly quickly wasted ; we find sometimes
portions of it encircled by the cancer, and sometimes its yellow tinge is
difixised through parts of the cancer, as if they were thoroughly min-
gled ; but both these appearances are limited to the superficial and
more lately formed portions of the growth : they are always lost in the
central and older parts. There is the same gradual disappearance of
the elements of the skin when it is involved ; so that we might say that
the regular process in the formation of a cancer of the breast is, that u
the cancer-substance increases, so the natural tissues involved by it de-
generate and waste. I repeat, we might say this, if it were not for the
fibrous tissue that intervenes among the lobes and ducts of the gland;
for this seems either to waste more slowly than any other part, or to
remain unchanged, or even in some cases to increase with the progress
of the cancer. To these conditions of the fibrous tissue I shall again
refer.
* In his Archiv, B. i, p. 95.
"CARCBE juice" AND "8TE0MA." 526
Now, if to the progreBBive varietiee that may arise, throngh these
ohangea in the involved tissucB of the breast, we add that parts of the
proper oaocer-sabstance may degenerate or waste, or may vary in their
method of development, while other parts are merely increasing, we
may apprehend, in some mesBure, the meaning of those great varieties
of appearance which we find in any large series of cancers. They are
munly dne to the different modes and measures in which the constittt-
eots of the canoer-snbstance and of the original tisBuee are, first, min-
gled together, and then increased, degenerated, or absorbed.
After this necessary explanation, let me retarn to the descriptioa of
the mingled mass. We find, as I have Baid, in any ordinary cancer of
the breast, a grayish basis, which contains the proper elements of the
cancer, bat which is or may be intersected by visible fibres, dncte, and
yellow lines or spots, which belong chiefly, or entirely, to the textures
of the breast. One may nsnally press or scrape, from the cut surface
of sach a cancer, a pale grayish, thick, and turbid fluid, which is easily
diffused through water, and is much more abundantly yielded when the
cancer has been macerated for a day or two in water. It is not creamy,
but rather like thick gruel, and is usually composed of a mixture of the
proper cancer-substance, and of the softened tissues of the breast, and
the contents of the bloodvessels and remaining gland-ducts. It is called
the " cancer juice," and what is left after it is expressed, is called the
" stroma" of tbe cancer (see, further, p. 581). I should state, how-
ever, that about the central and deeper parts, or sometinies in tbe whole
masses of the hardest cancers, no such fluid can be obtained ; they yield,
to pressure or scraping, only a small quantity of yellowish fluid, like
turbid serum.
The remaining description of the bard cancer must be, chiefly, from
its microscopic appearances.
In very thin sections it is not difficult to see the infiltration, or inser-
tion, of the cancer-substance in the interstices of the affected tissues.
It may be most clearly seen in sections of
any part of the skin recently invaded by Fig. 84.»
the cancer, for here, in the meshes of the
retionlated connective tissue, the cancer-
particles are qnite distinct, filling every in-
terval, and not obscured by the d^ris of
the gland-ducts and their contents. I am
not aware of any more orderly plan of ar-
rangement of tbe materials of the cancer
than that which may be expressed by Baying
th»t they fill the interstices of whatever
tissue they may lie in. They may either
* Fig. Si. CaDceT-cella filling interaticeg among the fa
ibe *kiii ol ■ btnut. HagniQed bUiui SOO timea.
626 MICROSCOPIC ANATOMY OF
expand these interstices, when they accumulate quickly and abundantly,
or, when they shriyel and degenerate, they may allow the tissues to
collapse or contract.
The elementary structures of the cancer-substance, thus infiltrated
in the breast, are chiefly two : namely (1), certain cells and other cor-
puscles ; and (2) a fluid or solid blastema, or nearly homogeneous sub*
stance, in which these lie imbedded. We may study these, but, it most
be admitted, in some confusion and uncertainty, in the material obtained
by the pressure from the cancer.
The blastema, or intercellular substance, presents, I belieTe, no pecu-
liar features. As obtained by pressure, it is made very impure by the
admixture of blood and other fluids ; and it would be unsafe to describe
it more minutely than as a pellucid or dimly granular substance, which
in certain cases, yet I think rarely, assumes an appearance of fibrous
texture. The corpuscles of hard cancer are chiefly nucleated cells. In
ordinary cases, and where the cancer has not been deflected from its
normal course, their characters are constant and peculiar, and may be
described as for the types of " cancer-cells" (Fig. 85).
Fig. 85.»
In shape they are various. Usually a large majority are broadly
oval, or nearly round : in some specimens, indeed, all may have these
forms ; but, in other specimens, though these prevail, yet many cells
have one or more angles, or outdrawn processes, and some are pyriform,
some fusiform, some reniform, some nearly lanceolate.
It would be useless to describe all the shapes that may be found, for
we can, at present, neither explain them, nor connect them with any
corresponding differences in the general structure or history of the can-
cers in which they severally occur. But we may observe, as Bruch and
others have done, on this multiformity as a feature of malignant struc-
tures : I know no innocent tumors, except the cartilaginous, in which
it is imitated.
In size, the hard cancer-cells range from tb^ou^^i ^^ *^ 5^<5h to ^Jjjth
of an inch in diameter. Their medium and most frequent sizes are from
ja'o^th to TD^JU^t : the smaller dimensions are usually found in the can-
cers of quickest growth.
In structure and general aspect they most nearly resemble, I think,
the secreting gland-cells. Examined immediately after removal, and .
without addition of water, they appear clear and nearly pellucid ; but
* Fig. 85. Cells and free nuclei of scirrhous cancer : from breasts. Magnified aboat
500 times.
80IBBH0U8 OR HABD CANOBB. 627
changM qnckty enBoe, which water occeleratee, and which bring them
to the oharacterB more geoerallj ascribed to cancer-cells. They become
nebnlotu, or dimlj granular, or dotted, as if containing minute mole-
onlea; and they look no longer quite colorless, but very lightly grayish
or yellowish. The cell-wall is, if it can be seen at all, peculiarly thin
and delicate : but it is often impossible to discern any ; and my belief
is, that the cancer-cells are often only cell-shaped masses of some soft
though tenacious substance, within which are nuclei.
The nuclei in hard cancers are more constant in their appearanoes than
the cells, and, I think, are even more characteristic. They are always
comparatively large, having an average long diameter of about gtVo^
of an ueh, and varying from this aise much less than the cells do from
theirs. They are regular, oval, or nearly round, clear, well-defined,
•oarcely altered by commencing decomposition, or by water, or any
moderately diluted test-Bubstance. A single nucleus is usually con-
tuned in each cell ; two nuclei in a cell are frequently found, bnt not
in all specimens of hard cancer ; more than two are rare : when more
than one are found in a cell, they are generally smaller than those that
are single.
Among the materials of a hard cancer, a certain number of free nuclei
are usually found. It may be difScult to prove that these have not es-
caped from cells during examination : but I think they are naturally
free nuclei ; for they are often larger than those contained in cells, and
they sometimes deviate from the common shape, after methods which
are more often noticed among the corpuscles of medullary cancers, and
which will be more fully described in the next lecture.
Each nucleus has one, two, or rarely more, nucleoli, which, like itself,
are large in comparison with the ordinary proportion between nucleoli
and cells, and are peculiarly bright and well-deiined.
These seem to be the normal elements of hard cancer ; and such as
we find them in the breast, such are they, bnt less mingled and confused
with other forms, in the hard cancers of the skin, the bones, and other
organs. Indeed, these characters are bo nearly constant and so pecu-
liar, that an experienced microscopist can very rarely hesitate in form-
ing upon them adiagnosis of the cancerous nature of any tumor in which
they are observed.
But it would seem as if hard cancer seldom long maintained an un-
disturbed course; for we seldom find these
atractures, without finding also cells mingled ^K- W*
with them, in which degeneration or disease ^^ »_-^ '
has taken place. Some of them are withered 1©;^^ -flf '.ls>
(Fig. 86) ; some contain minute oily particles ; "X^^is'li .^^lAf-
Bome are completely filled with such parti- pi^'U '■'•'^^ ^
eles, or are transformed into granule masses ^^"'^■(u:'!^'
* Fig. 86. Withered bard eanCflrcflllB, wi(b dfcbru.
628
MICROSCOPIC ANATOMT OF
Pig. 87.*
(Fig. 87) ; and with these we always find abundant molecular and gra-
nular matter, in which, as in the debris of cells, the nuclei lie loose.
This debris, too, let me add, is always increased when the cancer is
kept for a day or two before examination, and when water acts upon
it. The loss of clearness by the cancer-cell, of which I hare already
spoken (p. 526), is only the first of a series of changes,
in the course of which the material of the cells breaks
up into molecular and amorphous debris : fragments
of it may hang about the nuclei ; but, finally, the cells
are completely disintegrated, and the nuclei, com-
paratively unchanged, are set free.
Among the tissues of the breast itself which are in*
yolved by the cancer, the gland-lobes, I hare already
said, are quickly removed ; but their debris may con-
tribute to the molecular matter which is mingled with
the proper corpuscles of the cancer.
The larger gland-ducts, involved in the cancer,
often appear thickened ; and their contents, which are
usually a thick, turbid, greasy fluid, present abundant
granule-masses, withered cells like epithelial cells of
ducts, fragments of membrane, free nuclei shrivelled
and deformed, molecular and granular matter: all
these being, I suppose, their natural contents, degenerate and disinte-
grated.
But the more remarkable and characteristic appearances are pro-
duced chiefly or in great part by the smaller gland-ducts, and the fibrous
tissue inclosed in the cancer. The former chiefly constitute that which
has been named " the reticulum" of hard cancer, and which has sug-
gested the name of Carcinoma reticulare for the specimens in which it
is well seen.f
The most usual appearances of what is now described as " reticu-
lum'* are two; and these may exist separately, or may coincide. In
one, which is the most characteristic, and, indeed, the only one to which
the name can apply, we see fine, branching, and variously interlacing
and netted lines, of an opaque-white, bufi", or ochre-yellow hue. They
appear as if formed of thickly sprinkled dots. They traverse the very
substance of the cancer ; and it is important to observe that when the
cancer occupies but a small portion of the mammary gland, these netted
* Fig. 87. Hard cancer-cells, showing the progress of fatty degeneration.
t Under the name of Carcinoma reticulare, Mailer included many cancers that could ooi
have been scirrhous or hard cancers. On this ground I think the name had better not be
retained; for, whatever the " reticulum'' be formed by, it is too accidental to be considered
a specific character, and is associated with too great diversities of other characters, to be used
even arbitrarily, for the determination of a species. It is not even confined to cancers; cor*
responding appearances may be found in fibro-cellular, cartilaginous, fibro-nucleated, and
probably several other tumors (see pp. 408,438, 518).
8CIRBH0U8 OR HARD CANCER. 629
lines are found only in that part of it which corresponds with the gland-
substance.
In the other and rarer form of what is also called ^' reticulum," we
find larger dots or small masses of ochre-yellow substance, such as are
compared to seeds. These lie more widely scattered in the substance
of the cancer, and may often be pressed from it, like the comedones, or
retained white secretion from obstructed hair-follicles.
I believe that these yellow '^ seed-like bodies," which are apt, if we
examine them superficially, to be confounded with the degenerate con-
tents of the larger ducts, are always small portions of the cancer, degene-
rated and softened, or partially dried. We find in them abundant
granule-cells and granule-masses, some entire, some in fragments ; frag-
ments, also, of granular and nebulous blastema (as it seems), and often
of nucleated membrane ; and these lie in molecular and granular mat-
ter diffused in liquid, with minute oil drops, and often with crystals of
cholesterine. But with these products of complete degeneration, we
may commonly find, also, cancer-cells, of which the great majority are
either degenerate, filled with fatty matter, like granule-cells, or disin-
tegrated ; or else (when the substance is drier) shrivelled and dried up,
like the lymph and pus corpuscles that we may find in chronic inflamed
lymphatic glands (Figs. 86, 87).
Similar to these in their component structures are the larger masses
of friable yellow substance, like tuberculous deposits, which are rarely
found in hard cancers, but are very frequent in the medullary cancers.
Now, these appearances of yellow spots, — whether seed-like or in
larger masses — are not exclusively found in the breast, or in glandular
structures : they may be seen in any hard cancer, and are yet more
frequent in soft cancers in all organs. But the fine branching and
netted lines that compose the more characteristic reticulum are found,
especially, in cancers of glandular organs : and in those of the breast I
have so often found, among the products of degeneration in them, what
appeared to be portions of withered ducts and epithelium, that I feel
nearly sure that the essential characters of this reticulum, in the scir-
rhous cancers of the breast, are to be ascribed to the minuter lactiferous
tubes which, involved in the cancerous infiltration, are now, with their
contents, compressed, degenerate, and wasting.'*'
Lastly, respecting the connective tissue, involved in the cancer, the fate
of this, I have said, appears diffierent in diffierent cases. We sometimes
meet with a cancer of the breast which, having just involved the skin,
shows us the interlacing bundles of cutaneous fibres spread out or ex-
panded by the insertion of the cancer-structures among them (as in
Fig. 84). The skin in such a case appears thickened, and its section
is glossy, gray, and succulent, like that of hard cancer, but dimly marked
with whitish fibrous bands. In other and more frequent cases the marks
* We may compare tbem with a kind of black reticulum seen in cancers of the lungs
or broocliial glandi.
B8 OF TISSUES IM SOIKftl
are absent ; and the fibrous and elastic tisaues of the skin are not to k
found : we may presume that they have been absorbed u ihn «unr-
structures increased. I think this removal of th« fibrons And vImuc
tissues is the more frequent event, both in the skin nnd in tbt^and;
yet in some of the hard cancers, and in the central hanlott puts «f
others, the fibrous tissue of the gland — all thut which oucoinpaw tht
gland-tubes and becomes, proportionally, so abundant when ihe nerM-
ing structures waste — all appears to be even incrttaeed and ctmdmMi
or indurated.
Such cancers as these have been regarded ns examples of » tpMU
form, named Carcinoma fibrosum, and the fibrous tissue found in Aim
has been commonly considered as a proper caiiceroua atnieinr*, ■ n^
suit of the fibrous development of the cancerous blulema. No*. I
shall have to refer (p. 541) to certain {genuine instances of fibrow iuii
cancer, as occurring especially in the ovaries ; and I would not imj
that part of the cancerous material prcnluced in a breast may k dt-
vcloped into fibrous tissue; but I am sure that in the large majontrtf
cases, the fibrous tissue \Tbich is found in a cancer of the breast a mlj
that which belonged to the breast itself, and which, involved in the en-
cer, may now be either wasted or increased. For the fibrous tiMite ti
hard cancers of the breast is not like morbid or new tisaue, nor like th«
which is found in really fibrous cancers, but is like the Dstarsl poniiK-
tire tissue, cither healthy or indurated and condensed. It is alM jpsf-
rally mixed with fibres of elastic tissues, such as are intermingled «itt
the natural areolar tissue, hut never, I think, occur among the proftf
constituents of cancer, and are very rare in even the more higIlly«^
ganized of the innocent tumors. I may add, in confinnatiou of tkii
view of the nature and origin of the fibrous tissue in esncen of tk
breast, that when hard cancer occurs in organs which have little «•«
fibrous tissue— *such as cancellous bone, the brain, the liver, or llielj*
phatic glands — it presents little or none of the same tisane: hnwrw
hard it may be, it is formed almost entirely of corpuscles.' Tbe#
ference in this respect is often, indeed, very striking between die W
cancer of the breast and that of the correspomling arillw^ gluk
Both may be equally hard and manifestly identical in natnre; yet, wUi
the cancer of the breast may include abundant fibrous tissue, tiat <■
the glands may have scarcely a trace.f
I have dwelt the more on this point becanse the current nelkMJi'
* Hr.t. tetpeetint ihe hard cancM of the brain, a oaav wnll ilvKiitiMl bf Di. Radtn
(Monihly Joum, Dec. iMn). I ihink all thai Virchow. Leben, and aun** oAmi t>»
wiiitpn, ii quite couincnt with Ihis tIsw, ihongh Ihe^ iMm to beillau in aeeapUi* k,
f Kit wvra atmnite Ihal in lome bard cancers the flbcou* liaiue ofth* lavolndap*^
F, while ia ottaen it i* ditninlalitil. the atnaRsneai mar Im mada u> aaaoi ks If ■*
'e Blaring example* of ilitferenc« amooK cmncert ot bono>i — fioin the ■rodlap aOBaikq
bard cancpn, in whic>h the oufdus liuiie wholly dii«pp«ans to tha meilullafr oaaMn ■•
wliich Ihe oawmii liuuc increiies oontnieiDuntel]' witb Iba eaiK«r and pgwaoai la^liii
■ iponiiy ikeleioD or framewoik.
8CIRRH0U8 OR HARD OANCBR OF THB BREAST. 681
describing all cancers as composed of a peculiar '^ stroma/' the meshes
of which are filled by a peculiar "cancer juice/' appears to me very
deoeptivcy and often incorrect. The expressions, as they are commonly
used, imply that the fibrous tissue or stroma, and the cells and other
materials which form the juice, are alike proper and essential to the
cancer. But I believe that in the large majority of cancers of the
breast the only "stroma," the only substance that would remain, after
removing all that is cancerous, would be the structures of the breast
itself. And so, in other cancers, my belief is, that if we except the
rare examples of the really fibrous, and osteoid cancers, to which I
shall hereafter refer, there are few in which more than a very small
quantity of fibrous tissue is formed.
In the foregoing description I have had in view, almost exclusively,
the forms of hard cancer which are most frequent in the breast ; in-
stances of the ordinary or typical characters of the disease. But as I
said at the outset, the deviations from these medium forms are neither
few nor inconsiderable, even though we do not count among them any
of the varieties of appearance which are due to degeneration, or to
disease of the cancerous structure, or to varying conditions in the parts
about the mammary gland.
And, first, varieties appear which may be referred to different degrees
of actirity or intensity of the disease. The examples which I have
hitherto chiefly described might hold a middle place in a series at the
opposite ends of which would be those of what have been sometimes
called the "acute" and the "chronic" cancers.'*'
The well-marked examples of the former kind are distinguished, not
only by rapid progress, but by structure. They are scarcely to be
called hard — they are, at the most, firm, tense, and elastic ; and they
may even, though not morbidly softened, present a deceptive feeling of
fluctuation. Their cut surfaces do not become concave ; they are suc-
culent, and yield abundant fluid upon pressure ; they are often suffused
with vascularity, especially about their borders. The quantity of can-
cer-structure in them is very large, in proportion to the quantity of
gland in which it has its seat. Hence the section of an acute cancer
appears more homogeneous, and its growth produces a manifest enlarge-
ment or swelling, the morbid material expanding the tissues around and
involved within it. The surrounding tissues, also, are less closely con-
nected with the cancer than they usually are, and it may appear like a
distinct isolated tumor, rather than an infiltration.
In all these cond itions the acute scirrhous cancers approximate to the
characters of medullary cancers ; and perhaps the expression is not
unjust, that they are examples of an intermediate form of the disease.
* Most of the acute fonns are such as some call elattie cancers: most of the chronic
would be classed as fibrout cancers by those who adopt that term. ** Hypertrophic" and
* atrophic" have also been applied to them as terms of contrast.
682 ACUTB AND CHRONIO CANCBR.
And the approximation is shown in some other characters, especially in
their more rapid growth ; in their usually affecting those whose mean
age is below that of the subjects of the harder and more chronic can-
cers ; and in the signs of larger supply of blood.
In the chronic hard cancers the opposites of all these characters are
found. The cancerous mass is comparatively small; and, as time
passes, it often seems to shrink and contract, rather than increase. It
is intensely hard, knotted, and dry ; the adjacent tissues appear tight-
drawn to it, and firmly adherent ; and on its cut surface, which usually
appears deeply concave, it may show more of the increased and indurated
fibrous tissue of the breast than of the proper cancer-substance. All
the history of the chronic cancers accords with these signs of inactivity :
they occur generally in those that are beyond the mean age ; they are
attended with no increase of vascularity ; and if the skin becomes in-
volved in one, it is only ruddy or palely livid at the very seat of adhe-
sion. The tissues of the breast itself usually appear to suffer a corre-
sponding atrophy ; the gland commonly shrivels, and the skin becomes
lax and wrinkled, or else is filled out with superabundant fat accumulating
around the shrinking gland.
Either of these forms of cancer may affect, in some cases, the whole
gland ; in others, only a portion of it. The characters of both are most
marked when they occupy the whole gland, for now the enlargement
attending the acute cancer, and the shrinking that accompanies the
chronic, are most manifest.
In general, the respective characters of the acute and the chronic
cancer are consistent throughout all their course ; yet cases are not
rare in which a scirrhous cancer has shown all signs of rapid progress
at the beginning of its career, but, after a time, has inexplicably re-
tarded its course, and passed into a chronic state. Nor, on the other
hand, are those rare in which patients are seen dying quickly, because
a cancer which has been slowly and almost imperceptibly progressive for
several years, at length assumes the rapidity and destructiveness of an
acute inflammation.
A second series of hard cancers, deviating from the usual forms, con-
sists of cases in which the nipple and the skin or other tissues of the
mammary gland are peculiarly affected.
Commonly the hard cancer extends from the mammary gland to the
nipple and areola, involving these as it may any other adjacent part.
When seated at or near the centre of the gland, it commonly draws
down the nipple, which descends as it were into a round pit sunk below
the general level of the breast. As it extends, also, the cancer-structures
deposited in the nipple make it hard, or very firm and elastic, inflexible,
and comparatively immovable. But the changes which thus usually
occur later, or in a less degree than those in the gland, may commence
or predominate in the nipple or the areola. The former may be found
SCIRRHOUS CAKCER OF THE NIPPLE, AREOLA, ETC. 533
quite hard and rigid ; or, in the place of the latter, there may be a thin
layer of hard cancerons substance, with a superficial ulcer, like an
irregular excoriation, while the structures of the gland itself are yet
healthy.
In other cases, we find the skin over and about the mammary gland
exceedingly afiected. In a wide and constantly, though slowly widen-
ing area, the integuments become hard, thick, brawny, and almost in-
flexible. The surface of the skin is generally florid or dusky with
congestion of blood ; and the orifices of its follicles appear enlarged, as
if one saw it magnified, — ^it looks like coarse leather. The portion thus
affected has an irregular outline, beyond which cord-like offshoots or
isolated cancerous tubercles are sometimes seen, like those which are
common as secondary formations. The mammary gland itself, in such
cases, may be the seat of any ordinary form of hard cancer ; but I think
that at last it generally suffers atrophy, becoming, whether cancerous
or not, more and more thin and dry, while the skin contracts, and is
drawn tightly on the bony walls of the chest, and then becomes firmly
fixed to them.
I
I might add to the account of these deviations from the ordinary
forms of cancer of the breast, notices of some others ; but these may
suffice ; and if it be remembered that each of these, as well as of the
more common forms, is liable to change by the various degenerations
and diseases of the cancer, enough will have been said to illustrate the
exceeding multiformity in which the disease presents itself in the breast.
Something, however, must be added respecting the characters of scir-
rhous cancers in other parts of the body ; and from these I will select
chiefly those parts in which it has the greatest surgical interest, or has
received the least attention from morbid anatomists.
In the Lymphatic Glands, the scirrhous or hard cancer appears
very frequently as a secondary disease; indeed there are few cases
in which cancerous patients reach their average of life without affection
of the glands connected with the organ primarily diseased. But, as a
primary disease, scirrhous cancer of the lymphatic glands is very rare :
the cancer which most commonly appears first in them is the medullary ;
especially, I think, that of the firmer kind.'*' A specimen is in the
Museum of St. Bartholomew'8,t which shows well-marked scirrhous
cancer in an inguinal gland. The gland is increased to an inch and a
half in length, and, while retaining its natural shape, nearly the whole
* The Index will, I hope, in some measure correct the disadvantage, which is here evi-
dent, of separating the accounts of the different forms of cancer in the same organ. The
disadvantage is, I think, more than compensated by the avoidance of confusion in the de-
•eriptions of the different forms; and in the Index the reader will find, under the title of
each chief organ or tissue (so far as they are here described), the references to all the forms
of cancer occurring in it.
f Series xxi, 3.
584 SCIRRHOUS OR HARD GANOBR
of its proper texture appears replaced by structares exactly resembling,
in hardness and all other properties, the ordinary scirrhous cancer of
the breast. It was removed by Mr. Lawrence from a lady, who re-
mained well about three years after the operation, and in whom the
disease then recurred in another inguinal gland, which was also removed,
and presented the same characters. They were equally marked in the
progress through destructive ulceration which ensued in a primary
scirrhous cancer of the axillary glands, also observed by Mr. Law-
rence. I believe I saw a third instance in some inguinal glands, which
formed an exceedingly hard swelling in and below the groin ; bat I had
no opportunity for minute examination of them. There was no proba-
bility, in any of these cases, that any other part was the seat of cancer
before, or at the same time with, the lymphatic glands.
Gases sometimes occur in which the disease in the glands may be so
nearly coincident with that in the organ to which they are related, that
we may believe the gland-cancer to be primary, though not alone. And
sometimes the disease in the glands greatly preponderates over that in
the organ, even though its primary seat was in the latter. A woman
60 years old, was some years ago in St. Bartholomew's Hospital, in
whose right breast there was a hard lump, less than a pea in sise, which
felt exactly like a hard cancerous tumor imbedded in the gland. This
had existed unchanging for twenty years ; and in the right axilla a
cluster of lymphatic glands had been rapidly enlarging for twelve
months, and now formed a great mass so uniformly hard, heavy, and
nodular, as I have never seen formed by any glands but those affected
with scirrhous cancer. The case is, however, imperfect, for the patient
would submit to no operation, and there may remain some doubt as to
the nature of the small tumor in the breast.
All these, however, are comparatively rare events. The ordinary
course is, that after the scirrhous cancer has existed for a time (the
length of which seems at present quite uncertain), in the breast or any
other organ, the lymphatic glands in and near the route from that organ
towards the thoracic duct become the seats of similar disease. I shall
speak elsewhere of the probable method of this extension of the cancer
to the glands. Its effects are shown in a process which, in all essential
characters, imitates that preceding it in the organ primarily diseased.
Usually the cancerous material is deposited, and its structures arc
formed, in the first instance, in separate portions of one or more
glands. The separate formations appear as masses of very firm and
hard whitish or grayish substance, of rounded shapes, imbedded in the
glands, and contrasting strongly, as well in texture as in color, with
their healthy remaining portions. But, as the separate portions in each
gland enlarge, they gradually coalesce till the whole natural structure
of the gland is overwhelmed and replaced by the cancer. Similarly,
the same changes ensuing at once in many glands, they form a large
IN LYMPHATIC GLANDS. 585
and still inGreasing cluster, and at length, coalesce in one cancerous
mass, in which their several outlines can hardly be discerned.
The mmute texture of the hard cancer of lymphatic glands differs, I
believe, in nothing that is important from that already described in the
cancer of the breast. Only, in microscopic examinations, we find the
proper structure of the lymphatics, in the place of those of the mam-
mary gland, mingled with the cells and other constituents of the cancer.
Neither is there any essential difference in the mode of deposit of the
cancerous material ; it is, in both alike, an infiltration, though circum-
scribed.
Occasionally, it is said (but I have never seen it), the secondary can-
cer of the lymphatic glands is soft and medullary, while that of the
organ primarily diseased is scirrhous. Very often, before becoming
cancerous, the lymphatic glands enlarge without hardening, — through
^^ simple irritation," as the expression is. From this condition they
may subside after the removal of the primary cancer, or when corre-
sponding ^^ irritation" in it is relieved. But the condition, whatever it
may be, is probably not one of mere slight inflammation ; for glands
which may have thus subsided, or which have not been visibly affected,
may become the sole or primary seats of recurrent cancer, even two or
more years after the removal of the primary disease. There seems to
be a peculiar state of liability to cancer, long retained in lymphatic
glands, sometimes testified by enlargement, but often not discernible
except in its results.
Scirrhous Cancer of the Skin is another of the affections commonly
occurring secondarily, yet sometimes appearing as a primary disease.
Its occurrence, when the disease extends continuously from the mam-
mary gland, is already described. In a similar manner it may be found
extending from lymphatic glands, or any other subcutaneous organ ;
and I have described (p. 533) how it sometimes precedes and surpasses
in extent the scirrhous cancer of the breast. But its most frequent
appearance, in connection with cancer of the breast, and that which is
imitated when it occurs as a primary disease in other parts of the skin,
is in tubercles or rounded hard masses.
Such tubercles are generally grouped irregularly, but in constantly
widening areas, about the primary disease in the breast ; in other parts,
and as primary cancers, they may be single or numerous. They are
almost incompressibly hard, tough, circumscribed masses or knots ; they
are usually of oval, flat, or biconvex form, or, when large, are tuberous
or lobed; they are imbedded, as infiltrations of cancer-structures, in
the exterior compact layer of the cutis. They are generally equally
prominent above, and sunken beneath, the level of the surface of the
. skin ; and this condition is commonly acquired as well by those which
commence like little prominent papulae, as by those which at first ap-
pear like knots just subcutaneous. The skin covering them is thin,
586 SCIRRHOUS OR HARD CANCER OF THE MUSCLES.
tense, and shining ; it is usually of a deep ruddy pink color, tending i^
purple or brownish-red, or it may seem tinged with brown, like a pig-
ment mark. This change of color extends a little beyond the border
of the cancerous mass, and then quickly fades into the natural hue of
the skin. Such cancers are movable with, but not in, the surrounding
skin, and even with it the mobility is very limited when they are large
and deep. They may be found of various sizes; in circumscribed
masses ranging from such a size as can just be detected by the touch,
to a diameter of two inches ; or, when diffused in the skin, occupying it
in an expansion of hardly limited extent.
The minute structures, equally with the general characters, of the
scirrhous cancers of the skin, are, in everything, conformed with those
already described ; and the characters of cancer-cells, and their mode
of disorderly insertion in the interstices of the natural tissues, are in no
parts more distinct.*
In general, I think, the scirrhous cancers of the skin have a chronic
course, not painful, nor soon ulcerating ; but, as primary diseases, they
are too infrequent for a general history of them to be written at present.
I have seen only four examples of them independent of previous cancer
in other parts. In one of these the seat of disease was nearly the whole
skin of the front of the left side of the chest of a woman 73 years old;
in another, it was in the skin of the leg, in the form of cancerous tuber-
cles about the knee, of a woman aet. 65 ; in another, an elderly man's
scalp had two large, hard, cancerous masses in it; in a fourth the
disease was in the scrotum of a man 53 years old ; but I believe the
elementary structures of scirrhous cancer were mingled with others
resembling those of the more frequent epithelial soot-cancer of the same
part.f
In the Muscles scirrhous cancer is commonly associated with its
most frequent form in the skin : that, namely, in which it occurs in
groups of tubercles about the primary disease of the breast. We may,
indeed, draw a close parallel between the secondary cancers in the skin
and muscles respectively ; for in both parts alike we find, in some cases,
* In the foregoing account I have not had in view that which is commonly called the
"cancerous tubercle of the face,' and which so often occurs as the precedent of the destruc-
tive process constituting the so called " cancerous" or '* cancroid ulcer" of the face in old
persons. I have not been able to examine minutely one of these tubercles before ulceration,
but all I have seen of the materials forming the base and margins of the ulcers whicb follow
them, and all the characters of their progress, make me believe that no cancerous structurf,
whether scirrhous, epithelial, or any other, exists in them. I shall revert to this subject io
the lecture on Epithelial Cancer.
f This specimen is in the Museum of St. Bartholomew's. Cases of cancer of the skin are
related by Lebert, Walshe, and others, in their appropriate chapters ; but it is not clear that aof
of them were primary scirrhous cancers. Those which were not epithelial cancers appear
to have been either medullary, of the firmer sort, or (in Lebert's cases) melanotic. All these
forms of cancer are more frequent in the skin, as primary diseases, than that which I have
described : they will all be considered in the following lectures.
B0IBBH0U8 OB HABD CANOEBS IN THE BONES. 537
discrete eanceroos tubercles, in others extensively diffused cancerous
deposits; and in the muscles, as in the skin, the latter form occurs espe-
cially when the disease extends continuously ; the former when it is
multiplied contiguously to its primary seat.
I have never seen a primary scirrhous cancer in a muscle ; and only
once have seen such a cancer forming a distinct isolated tumor in an
intermuscular space. It may be doubted, indeed, whether this tumor
were the primary disease ; yet, because of the exceeding rarity of scir-
rhous cancers in any other form than that^f infiltrations of the tex-
tures of parts, it deserves mention. It was taken, after death, from a
man 54 years old, in whom it had been observed for a month, and who
died, exceedingly emaciated and exhausted, with similar disease in his
axillary and bronchial lymphatic glands, his lungs, muscles, occipital
bone, and other parts. This tumor was about four inches in length,
oval, surrounded by a distinct capsule of connective tissue, and seated
between the brachialis anticus and biceps muscles, outspreading both of
them. It had the same hardness, weight, and density, and the same
microscopic cell-structures, as the ordinary hard cancers of the breast ;
it Was milk-white, slightly suffused with pink and gray, and distantly
spotted and streaked with ochre-tints. The other cancerous masses had
for the most part the same characters ; but some, which by their size
and positions might certainly be considered as of latest production, were
soft, and like the most frequent medullary cancers.
In the BoNBS, as in the muscles, the scirrhous cancer seldom, if ever,
occurs, except as a secondary disease : the primary cancers of bones are,
I think, always either medullary, osteoid, or colloid. The structures
of the scirrhous cancer may be infiltrated or diffused among those of
the bone, or they may form distinct masses ; but in neither case do they
so increase as to form considerable tumors. In some of the cases of
infiltration, the cancerous substance is diffused through the cancellous
tissue of the bone, while its walls are comparatively little changed : in
others all the bony structures are expanded into an irregular frame-
work of plates and bands, the interstices of which are filled with cancer-
ous substance, hard, elastic, gray, and shining.'*' On the other hand,
when separable cancerous masses are formed, they are usually round or
oval, or adapted to the shape of the inner walls of the bone, within
which they are, at least for a time, confined. They generally appear
as if, while they were growing, the original bony textures around
them had gradually wasted or been absorbed, making way for their
* Nos. 822~3 in the College Museum are examples of the first form j and No. 5 (Ap-
pendix) in that of St Bartholomew's may exemplify the second. The latter specimen was
taken ftoro a case in which a cancerous femur was broken eight months before death, and
the new bone, with which it was repaired, was infiltrated with cancer as well as tbe ori-
ginal textoiet.
a5
S0IRBHOD8 OR HAKD OAKCKR '
' And thus the growth of the bard esocer, with ab>
sorption (whether prerions or cooseqaent) of the
bone around it, may Gontinne till not only the
medullary tissue, but the whole thickness of the
wall, is removed, and the cancer may project
through and expand beyood it, or may alone fill
the periosteum, retaining, with very little cbange,
the original shape and size of the bone.f
In both these sets of cases the canoer-cells are
alike, and they form, without fibrous tissue, a hard,
or very firm, elastic, grayish substance, sbining,
and sometimes translucent, sometimes with an' ob-
scure fibrons appearance. The likeness to the
common hard cancer of the breast is complete, in
both general and microscopic characters; and not
less complete the contrast with the usual forms of
the medullary cancer, which, as I have said, ia the
more frequent primary disease of the bones. In-
termediate specimens may, indeed, be found ; yet,
on the whole, the contrast between medallary ud
scirrhous 'Cancers is as well marked in the bones
as in any other part.g
The bones thus cancerous become liable to be
broken with very slight forces ; and to these con-
ditions a certain number of tbeao-called spontaoe-
Dus fractures in cancerous patients maybe assigned.
But some are due to the wasting and degenerative
atrophy which the bones undergo during the pro-
gress of cancer, and which seems to proceed to an
extreme more often than it does in any other equally emaciating anil
cachectic disease.
The hard cancer of the INTESTINAL Canal, exemplified most fre-
quently in the upper part of the rectum, in the sigmoid flexure of the
colon, and, sometimes, in a very striking form, in the ileo-c£ecaI valve,
appears, usually, as an infiltration of hard cancer-structures in the sub-
mucous tissue. Here it is usually of annular form, and occupies the
* See, respeclirg the oecaiional " preparatory rarefactioti" of bones, pTevioua to cane*'™'
deposit* in Ihem, (he eicellentoWrTatjonsorWdshe (p. 555)BnJVirchow(Archi., 1,13")
t Ae in Nos. 817-8-9, in the Muaeiim of Ihe CoMege, and in leveial specimeos I'ldf
added lo Ihai of St. Bartholomew's.
I Fig. 88. Section of a humeros with hard cancer, as deaciibed above. Mus. of Si. Bir-
th olomew's.
J Me<lultary cancer may appear as a seconitaty disease in (he bones, aa well ii id t«1
olher pans, after pritnary icirrhous cancer in the breast. The oases I have eMinined wmU
make me think that the acirrhous cancer is, in these events, (he more frequent : twl M. 1^
ben {Traite des Maladies Cancereuees, p. 714) describes none but soft cancer* a* occtiritl
in the bones, whelher primarily or secondarily. |
Tbe mingling of
Kg. 89.*
07 TBI LARQB HfTESTINSS. 689
whole eircnmference of the intestine, in a length of from half an inch to
an inch. The cancer may, at the Bame time, or in other inatances,
occur externally to the musonlar coat, and in this caee is nsnally not
annnlar, bnt in separate tubercles, which, until ulceration ensues, pro-
ject with Sattened, and sometimes centrally depressed, round or oval
Borfaces, into the cavity of the intestine. Very rarely (it is said) it
may affect tbe whole circumference of a large extent of the rectom, and
may in the same extent involve many adjacent parts.
It BometimeB happens that the hard cancer of the submucous tissue
ia associated with growths of softer medullary cancer into the cavity of
the intestine, or with formations of colloid — -
these forms is certainly more frequent
in the digestive canal than in any other
part. Bnt that which is most remark-
able in the hard cancers of the rectum
(as an example of those of other por-
tions of the canal), is derived from the
tendency which the cancer has here, as
in other parts, to contract and con-
dense, and adhere to the parts around
it. To this it is due, that, when an an-
nular cancer of the rectum exists in the
submucous tissue, even the exterior of
the bowel appears constricted : instead
of swelling, the bowel is, even exter-
nally, smaller at the cancer than either
above or below it: and the stricture, or
narrowing of the canal, which would be
trivial if it depended only on the can-
cerous thickening of the coats, is made extreme by the contraction of
the coats around and with the cancer. The same conditions which, in
hard cancer of the breast, produce retraction of the nipple and pucker-
ing of the skin over the morbid growth, here produce contraction of the
muscular and peritoneal tissues around the growth, and a concentric in-
drawing of the growth itself.
With similar likeness to the hard cancers of the breast, those in the
intestine (in the rectum, for example) give rise to close adhesion of the
tissues around them to other adjacent parts. Thus the cancerous part
of the rectum may be fixed to the promontory or front surface of the
sacrum quite immovably ; or the colon moy become united to tbe uri-
nary bladder, or to some other portion of the intestinal canal.
Many other important facts in tbe history of this affection are con-
nected with the dilatation and hypertrophy of the intestine above the
' Fig. so. Hard eaneer or tbe recium, showing the roDnriction ot the periionml and
DHMCDlar coot* aroiind tbe cancer of tbe Bubmucoua tiuue. Hui. of Su Bartholomew's.
540 FIBROUS HARD CANCERS IN THB OVARIES, BTC.
Stricture ; the final paralysis of the dilated part, and the phenomena of
ileus chiefly due thereto, with displacement of the diseased part by the
weight of faeces accumulated above it ; the occasional variations of the
degree of stricture, according to the afflux of blood swelling the dis-
eased part, or its ulceration or sloughing decreasing it, and so, for a
time, widening the canal ; but these I need only enumerate, while I can
refer to Rokitansky* for ample accounts of them all.
The large intestine is, probably, next to the mammary gland and the
stomach, the organ in which the well-marked scirrhous cancer is most
frequently found as a primary disease. It very rarely, indeed, occurs
secondarily, except when extending to the intestine continuously from
some adjacent part ; and in this case, as it usually affects, at first, only
part of the circumference of the intestine, it may become much more
extensive without producing stricture ; for the unaffected part of the
wall may dilate so as to compensate, for a time, for the contraction of
the diseased part. Moreover, when it is a primary disease, the cancer of
the intestine is one of the forms in which the disease may exist longest
without multiplication, although often, even in its early stages, it is asso-
ciated with exceeding, and seemingly disproportionate, cachexia.
I have spoken of the occurrence of fibrous tissue in the scirrhous
cancers of the breast, and have said (p. 530) that this appears to be no
proper element of the cancer, but the natural connective tissue of the
part involved in the cancer, and often increased and condensed. If this
be always so, and if, as I have also said, little or no fibrous tissue be
found in cancers affecting organs which naturally contain none, it will
follow that the name Carcinoma fibrosum is not well applied to any ex-
amples of hard cancer described in the foregoing pages. Yet there are
cancers which contain not only abundant but peculiar fibrous tissue;
and these may well be called " fibrous cancers,*' and may be considered
as a distinct form or species, unless it should appear that they are always
associated, as secondary diseases, with scirrhous cancers of the more
ordinary structure ; so that we may suppose that the same material is,
in one organ, developed into fibrous tissue; in others, at the same tirae,
into cancer-cells.
The most remarkable examples of hard cancers with fibrous struc-
tures, that I have yet seen, have been in the ovaries of certain patients
with common hard cancer of the breast or stomach. f In these cases,
the place of the ovary on either or on both sides is occupied by a nodu-
lated mass of uniformly hard, heavy, white, and fibrous tissue. The
mass appears to be, generally, of oval form, and may be three or more
inches in diameter: its toughness exceeds that of even the firmest
fibrous tumors; and its component fibres, though too slender to be
* Pathologische Anatomic, III, 276 and 282.
t Museum of the College, Nos. 240, 2636 ; and of St. Bartholomew's, xxxi, 17, and, pro-
bably, xxxii, 14.
SCIRRHOUS OR HARD CANCER. 541
measared, are peculiarly hard, compact, closely and irregularly woven :
they are not undulating, but, when they can be separated singly or in
bundles, they appear dark-edged, short, and irregularly netted. With
these I have found only few and imperfect cancer-cells ; with more nu-
merous nuclei, elongated and slender. They are not mingled with elas-
tic or other ^^ yellow element" fibres.
But fibrous cancers are not found in the ovaries alone. Peculiar
Btiff-fibred tissue is sometimes contained, together with less abundant
cancer-cells, in the harder cancers connected with periosteum. So I
have seen it in the pelvis, and in the unossified parts of osteoid cancers,
where neither its relations nor its minute texture were such as to sug-
gest that it was morbidly increased periosteum. However, the occa-
sions that I have had of examining truly fibrous cancers have been too
few to justify any conclusion respecting the propriety of separating
them, as a distinct form, from the scirrhous cancers. And I cannot
complete my own imperfect observations with the records of other pa-
thologists ; for I think that none have endeavored sufficiently to dis-
criminate between the two kinds of fibrous tissue that may be found in
cancers ; namely, that which is developed during the growth of the can-
cer, and that which is derived from the original fibrous tissue of the
affected organ, whether in its natural state, or increased, condensed,
indurated, or otherwise morbidly changed. Yet the distinction is an
essential one ; for the former is truly cancer-structure, the latter is only
the structure in the interstices of which the cancer has its seat. A simi-
lar distinction will have to be made, in a future lecture, between the
osseous tissue that grows so as to form the framework, or interior
skeleton, of certain medullary cancers of bone, and that which is the
chief constituent of osteoid cancers : the one is a morbid growth of a
bone affected with cancer; the other is the proper cancer-structure
ossified.
LECTURE XXX.
SCIRRHOUS OR HARD CANCER.
PART II. — PATHOLOGY.
The former part of this lecture being devoted to an account of the
structures of the chief examples of hard or scirrhous cancers, I propose,
in this second part, to consider their history, their mode of life, their
pathology as contrasted with their anatomy. And here, even more
nearly than in the former part, I will limit myself to the histories of
those of the breast ; for concerning the primary hard cancers of other
parts, we have too few data for any general history.
542
INFLUBNCB 07 AGB AND SBX.
First, concerning the conditions favorable to the origin of these scir-
rhous cancers :
{a) They exist, in great preponderance, in women. Probably, of
every 100 cases of scirrhous cancer of the breast, 98 occur in women ;
and, I believe, it is chiefly this that makes cancer, on the whole, more
frequent in women than in men, for in nearly every other organ common
to both sexes the greatest frequency is, I think, found in men.
(() The age of most frequent occurrence of scirrhous cancer of the
breast is between 45 and 50 years. Nearly all records, I think, agree
in this. The disease has been seen before puberty ; but it is extremely
rare at any age under 25 ; after this age it increases to between 45 and
50 ; and then decreases in frequency, but at no later age becomes so
infrequent as it is before 20. ^
The following table, drawn from the records of 158 cases, of which
the diagnosis cannot be reasonably questioned, will illustrate the fore-
going statement :*
2 cases were first observed between 20 and 25 years of age.
4
u
t(
tc
25
tt
30
tt
9
»
u
u
30
u
35
tt
26
tt
u
u
35
tt
40
tt
33
tt
a
u
40
«
45
tt
40
u
u
u
45
tt
50
tf
17
u
u
u
50
tt
55
u
11
t(
u
^a
55
tt
60
u
9
u
it
tt
60
u
70
tt
6
(I
t(
u
70
tt
80
i(
1
ct
tt
above 80
158
In another series of 276 cases observed by myself, the numbers were:
Between 20 and 30
years
of age, .
5
« 30 " 40
((
41
" 40 « 60
((
. 122
« 50 " 60
tt
65
" 60 « 70
tt
35
" 70 " 80
IC
8
These numbers may represent the absolute frequencies of the occur-
rence of hard cancer of the breast at different ages. But it is more
important to know the relative frequencies in proportion to the number
* This and many of the following tables are drawn from a general table of 365 cases of
cancers of all kinds. Of the whole number nearly half were observed by myself. Of the
remainder I have derived about 50 from the records of the Cancer wards of the Middlesex
Hospital, for access to which I am much indebted to the surgeons of the hospital : more than
60 were very kindly communicated to me by Dr. Humphry ; others I owe to Mr. Lowe and
Dr. Paget : nearly all the rest were collected from the works of Wardrop, Langstaff, Baring,
Bruch, Bennett, and Sedillot. The ages assigned in this table are those at which, in each
case, the disease was first observed 6y the patient ; and no case is included which was re-
corded only, or chiefly, because it was an example of the disease occurring at an unusual
period of life.
SCIBRHOUS CANCER. 548
of women liying at each of the successive periods of life. To ascertain
this I have added to the cases in the first preceding table those tabu-
lated, in a nearly similar manner, by Mr. Birkett* and M. Lebert ;t
making a total of 854 cases originating between the ages of 20 and 80
years. Then, comparing the number of cases in each decennial period
of life, with the number of n^ omen alive in the same period in England
and Wales (according to the Population Returns for 1841), it appears
that the comparative frequencies, relatively to the whole number of
women, may be stated in the following numbers :
R«lAtiT« fV«qn«n^ of tilt
AflMi origin of bardoMMOT.
20 to 30 a
30 « 40 40
40 » 50 100
80 « 60 76
60 « 70 38
70 ** 80 32
In other words, the proportions between these numbers may repre-
sent the degrees in which the conditions of women's lives, at the succes-
sive decennial periods, are favorable to the first growth of hard cancer
in the breast.
One is naturally led to suppose that the great liability to cancer of
the breast between 40 and 50 years of age, and, especially, the maxi-
mum between 45 and 50, are connected with some of the natural events
that are then occurring in the nearly related reproductive organs ; such
as the cessation of the menstrual discharge, and of the maturation of
ova ; or else with the wasting and degeneracy of the mammary glands.
And yet it is difficult to prove such a connection with any single event
of the period.
The event which is generally regarded as most important is the ces-
sation of the menstrual discharge. But I find that among 52 women
with scirrhous cancer of the breast, ui whose cases this point is noted,
27 were still menstruating for at least a year after their discovery of the
cancer, and 16 had ceased to menstruate for a year or more previous
to it ; so that less than one-sixth of the whole number afforded examples
of the cessation of the catamenia and the discovery of the cancer occur-
ring within the same year.
The following table shows the ages at which menstruation ceased in
400 women,! and the ages at which hard cancer of the breast was first
detected by an equal number :
* On Diseases of the Breast, p. 218.
f Des Maladies CanoereuseSf p. 354. The particulars of both these tables accord very
nearly with those given above; but the numbers of cases below 20 and above 80, in Mr.
Birkett't table, are very large ; probably because be has included cases that were recorded
OD aeooant of their rarity in respect of the patients' ages.
X Frnh Dr. Guy's tables, in the Medical Times, 1845. The numbers in the third column
aie obcaiiied by doubling those in a table of 200 cases, collected from those of M. Lebert and
Mr. Birkatt, as well as from my own.
544 SCIRRHOUS CANCER OF THE BREAST.
Ages.
Below
35
35 to
40
40 '*
45
46 "
50
Above 50
CeiMtioii of Fi»t obterratioB
menftraAtloii. of the
36
62
9
51
140
159
41
78
101
123
400 400
All these calculations are sufficient to prove the great influence which
the events of life, at and about the time of the cessation of the men-
strual process, exercise in the production of the cancer ; but they do
not prove that the defect of that process has more influence than others
of the coincident events. This is confirmed by the observation that in
75 cases of cancer of the breast, commencing between the ages of 40
and 55, the disease began in 48 before the cessation of the catamenia ;
12 about the time of their cessation; 15 after it.* I think we may
most safely hold that the aptness of this time of life for the develop-
ment of hard cancer is chiefly due to the general failure of the process
of maintenance by nutrition, which usually has at this time its begin-
ning, and of which the most obvious natural signs are in the diminution
of the powers of the reproductive organs. It is in favor of this view,
rather than of any especial influence of the reproductive organs, or of
change in the mammary gland, that, so far as we can estimate, with so
small a number of cases as are yet on record, the ages of increasing
frequency of hard cancer in the male brea8t,t and of primary hard can-
cer in other organs, coincide with the results of the far more numerous
cases in the female breast.
This would hardly be so if it were the condition of the female breast
itself, or of any nearly related organ, that alone or chiefly determined
the greater frequency of the cancer at particular periods of life.
((?) To these conditions of sex and age, as favoring the production of
scirrhous cancer, we may add an hereditary disposition, and the effects
produced by injury or previous disease. The influence of these condi-
tions is not generally, but is often very clearly manifested. In 88
patients with hard cancer (including four men and four cases of hard
cancer of other organs than the breast) 16 were aware of cancer haying
occurred in other members of their families.
In 40 tabulated by M. Lebert, only 6 could be deemed hereditary.|
* Contribution to the Statistics of Cancer, by Mr. W. M. Baker, Med.-Chir. Trans., vol
xlv, 1862.
f The four nnen in whom I have seen hard cancer of the breast were respectively 40, 44,
48, and 52 years old at the discovery of the disease.
t The difference in the proportions of M. Lebert^s cases and in mine is probably due V>
my having reckoned as hereditary three cases in which members of the patients* families
had had cancers of the lip. These would be excluded as only ^cancroid" by M. Lebert;
and so excluded, and added to the non-hereditary cases, they make the proportionB very
nearly equal in both our estimates.
CONDITIONS OF GENERAL HEALTH. 645
Probably, therefore, not more than 1 in 6 patients with hard cancer
can be reckoned as having hereditary tendency thereto.*
The occurrence of hard cancer in many members of a family cannot,
then, be deemed frequent ; yet when it is observed, it is often too strik-
ing to leave any donbt about the reality of an hereditary tendency to
the disease.
{dj So, with regard to the effects of injury and previous disease, I
find that, among 91 patients, only 16, i. e. less than one-sixth, ascribed
the hard cancer to injury or any such local cause. The proportion is
so small (it is less, even, than that of the patients with other tumors, who
"^ ascribe them to the same cause),t that we might be disposed to deny the
influence of injury altogether, if its consequences were not, in a few
cases, so manifest and speedy.
(e) The influence of the single and married states is shown by Mr.
Baker (1. c.) in a table of 260 cases of cancer of the breast, in which
the proportions were :
Single, 23.0 per cent.
Married, 72.4 »
Widow, 4.6 «
The percentage of single women in cases of cancer of the breast is
therefore smaller than that in the female population generally.^
(/) I pass by some other conditions supposed to be favorable to the
occurrence of scirrhous cancers; such as mental distress, particular
occupations and temperaments. Concerning all these, the numerical
eyidence at present gained is insufficient to justify any conclusions.
But, respecting one point much discussed, namely, the general health of
women at the time when hard cancer is first found in them, I would
observe that a remarkable majority present the appearance of good
health. I find that in 91 cases in which I have notes on this point no
less than 66 patients presented the general characters of robust, or, at
least, good health ; 9 were of uncertain or moderately good health ; and
only 16 were sickly or feeble. § It does not follow that all these were
manifestly ill when the cancer began to form ; but, granting that it may
have been so, it would still appear that scarcely more than one-fourth
of the subjects of hard cancer are other than apparently healthy per-
sons. From all this it is evident, that, except in relation to the com-
parative liabilities of different ages, we have little knowledge of the
events that are, in any sense, the predisposing causes of hard cancer.
Indeed, so insignificant in their whole sum are those that are already
* Probably the proportion would be larger if calculated from a larger number of private
patieDts. See one of Mr. Bakers tables in the Lecture on the General Pathology of Cancer.
t See p. 348. Of 79 tumors not cancerous 15 were ascribed to injury or previous disease ;
i e. 1 in nearly 5J.
X See Insarance Guide and Handbook. London, 1857.
S From one of Mr. Baker's tables (1. c.) it appears that only 5.2 per cent, of the patients
with acirrfaoot cancer of the breast were in bad health at the first observation of the disease.
646 SOIRRHOUS CANCER.
ascertained, that, in a large majority of cases, the patient finds the can-
cer by some accident. She chances to touch her breast attentively, or
she feels some pain in it, or her friends notice that it is smaller or larger
than it used to be ; and now, already, there is a cancer of, it may be,
large size, of whose origin no account whatever can be rendered.
The fact last mentioned may explain why we so rarely have an oppor-
tunity of seeing what a hard cancer is like at its very beginning. I
have examined only three that were less than half an inch in diameter.
All these were removed within two months of their being first observed,
and all had the perfect cancerous structure, such as I have described as
the type. I believe they illustrated what is generally true, — namely,
that the cancerous structure has, from the first, its peculiar hardness.
The formation of it appears to be attended with gradually increasing
induration, only in the cases in which, from the beginning, it affects the
whole glands, and those in which it acquires even more than usual hard-
ness, by the gradual predominance of the increased and indurated
fibrous tissue.
From the extreme of smallness the cancer grows ; but at various
rates, in different cases, and even in the same case at different times. I
believe no average rate of increase can be assigned. Gases sometimes
occur, especially in lean, withered women, whose mammary glands share
in the generally pervading atrophy, in which two, three, or more years
pass without any apparent increase in a cancer ; and the progress even
of ulcerated cancer is, in such patients, sometimes scarcely perceptible,
even in the lapse of years. On the other hand, casefe are found some-
times of most rapid increase. I saw such a one last summer. A hard
cancer grew in five months from the size of the tip of a finger to a mass
five inches in diameter. This was in a woman 32 years old, in whom
the disease began while she was suckling, and immediately before, even
while suckling, she again became pregnant. Extensive and speedy
sloughing followed this rapid growth, and she died in seven months from
the first observation of the disease.*
We may very probably connect this singularly rapid progress of a
hard cancer with the condition of determination of blood to the breast
in which it occurred, and to the early age of the patient, — for, as a
general rule, though malignant tumors may, in their plan and mode of
growth, deviate never so widely from the normal tissues, yet for their
rate of increase they are dependent, in a certain measure, upon the
supply of blood and the general activity of the nutritive processes.
Hence it needs to be always borne in mind, in questions of operation,
that among the cancerous they who seem most robust may succumb
most quickly ; while the aged and the withered commonly live longest
and with least discomfort.
* This was the same case as that related by Mr. Gay, in the Proc. of Pathol. Soc, 1851-2,
p. 44i.
MODB OF GROWTH. 647
The increase of a hard cancer appears to be by gradual snperaddi-
tion of new particles on the surface of the mass already existing, and
in the interstices of the tissue immediately bounding it. It is a nice
question to determine how far from a mass of cancer already formed,
say, in the breast, the parts to be next added to it will be formed.
Practice professes to have settled this in the rule that the whole mam-
mary gland should be removed when only a portion of it is manifestly
cancerous. But whatever be the facts on which this rule is founded, —
and I believe they are enough to justify it, — they may be explained by
the advantage resulting from the removal of all the part in which the
cancer would be most apt to recur : they do not prove that cancer is
already present in the part of the breast that appears healthy. It is,
indeed, rare to find more than one cancerous mass in a mammary gland.
I do not remember to have seen it more than four times in about 100
cases ; and in one of these the second cancer appeared to have been
detached, not to have grown separately, from the principal mass. I
have looked with microscopic help at the tissues close by a hard cancer,
and have found, I think, cancer-cells one or two lines distant from the
apparent boundary of the chief mass, as if the disease had ^already
begun where neither the naked eye nor the finger could have discerned
it. Beyond this little distance I have not found reason to believe that
cancerous matter in any form exists in the parts of a cancerous mam-
mary gland that appear healthy.*
After an uncertain time and extent of growth of hard cancer, Ul-
OBRATION almost constantly follows. This may ensue in various ways ;
it may be accelerated or retarded by many extraneous circumstances,
according to which, also, its characters may vary ; but there are two
modes of ulceration which are especially frequent, and are almost na-
tural to the course of the cancer.
In one of these the ulceration begins superficially, and extends in-
wards ; in the other the changes leading to ulceration begin in the s.ub-
stance of the cancer, and thence make progress outwards.
The superficial mode of ulceration is commonly observed when the
cancerous growth has slowly reached and involved the skin. The best
examples are those in which the hard cancer first affects a border lobe
of the gland. From this, as it grows, it extends towards the skin, oc-
cupying, as it extends, the subcutaneous fat and all the intervening
tissues (Fig. 82)^ The skin, as the cancer approaches, whether raised
or depressed towards it, adheres closely to its more prominent parts or
to its whole surface. It becomes now, while cancerous matter infiltrates
* The existence of cancer-cells infiltrated amongst tlie tissues which surround the actual
cancerous tumor, and which to the naked eye may appear to be perfectly healthy^ has,
however, now been frequently demonstrated by more than one pathologist (Bennett on Can-
cerons and Cancroid Growths, p. 103; Van der Kolk "On the Formation and Extension
of Cancer-cells ;" Br. & For. Med. Chi. Rev., April, 1855, p. 390). For the changes occur-
ring in the tissues which lead to the formation of tlie cancer-cells, consult the note to par.
(3), Lect XXXV, Part II.
548 SCIRRHOUS CANCER.
it, turgid with blood, thin, tense, and glossy, florid or dusky red, or
livid or pale ruddy brown : the congestion does not extend far, nor very
gradually fade out, as in an inflamed integument, but is rather abruptly
circumscribed, just beyond the adhesion of the skin to the cancer.
In the next stage, the surface, in one or more places, appears raw,
as if excoriated ; or else, by some sudden stretching, it is cracked ; or
a thin yellow scab forms over part of it, which, being removed, exposes
an excoriated surface, and is soon reproduced. After a time the exco-
riated or the cracked surface appears as a more certain ulcer; scabs no
longer form, but a copious, acrid, thin fluid exudes. The ulcer is apt
to extend very widely ; and if there have been more than one, they soon
coalesce ; but they very rarely extend deeply, and their surfaces rarely
appear otherwise than pale, hard, dry, and inactive. The growth of
the cancer continues, as usual, after the ulceration ; and with the growth
and the involving of more skin, the ulceration is generally commensurate.
Now, the ulcer thus formed has, in itself, no so-called specific charac-
ters : examined by itself, it has not the features assigned to the can-
cerous ulcer ; we recognize its nature through that of the mass beneath
it. And yet there is much in the occurrence of this form of ulceration
that is characteristic. For we may always notice that, though it is
affected as if by the destruction of the skin, and is not unlike the ulcera-
tion that ensues over a great firm tumor that has stretched the skin to
its extreme of tolerance ; yet its occurrence is determined, not by the
bulk of the cancer and the tension of the skin, but by the adhesion and
confusion of the skin with the cancer. As the cancer approaches the
skin, 80 the skin, without any stretching, becomes thinner and thinner;
then its residue becomes cancerous; and then, at length, it is excoriated.
The cancer, exposed through the superficial ulcer, is not apt to be exu-
berant: it does not become or throw out "fungous growths;'* it mani-
fests no peculiar tendency to further ulceration. Granulations* of or-
dinary aspect, or such as are only too pale and hard, may cover it, and
it may often scab, or even skin over ; or, if it deepen itself, it may be
with no assumption of cancerous shape, but like a common chronic ulcer
deepening by sloughing or acute inflammation.
Far different from this, though sometimes superadded to it, is the
form of ulcer of the breast which begins in the substance of the cancer.
I will not now enter upon the discussions about the softening of cancers
(as a normal tendency of their structure), or upon those about their in-
terior suppuration : I will only state that, in certain cases of hard can-
cer, we find cavities filled and walled in with softened and disintegrated
cancerous matter. In these the dull, ochre-yellow, soft material, con-
sists mainly of degenerate cancer-cells and their dfebris. It may be
mingled with an ill-formed pus ; and as these mingled materials increase
and enlarge the cavity, so, finally, they are discharged by ulceration.
* These granulations are formed of cancer-structures; yet, let it be observed^ they take
the shape and construction of such as are formed in the healing of any oommon ulcer.
ULCERATION. 549
Thehr discharge leaves in the solid mass of cancer a deep excavated
ulcer, a cavity like that of a widely open abscess, except in that it is
all walled in with cancerous matter, the remains of the solid mass.
Then, as the walls of this cavity ulcerate on their internal surface, and
at the margin of the opening into it, so their outer surface is increased
by superaddition of the cancerous matter ; i. e, as one part of the can-
cer wastes, by ejection of its ulcerating surface, so is another part in-
creased. Hence the ulcer constantly enlarges : but the ulceration does
not destroy the cancer ; that increases the faster of the two, extending
more and more, both widely and deeply, and involving different tissues
more and more continually, to the end of life. In all its course it
yields a Ain, ichorous, and often irritating discharge, that smells
Btrongly, and almost peculiarly.
In all its later course, when not disturbed, this form of cancerous
ulcer has certain characteristic features, which are chiefly due to the
concurrent processes of ulceration at one surface, and of predominating
fresh formation at the other surface,, of the cancer. Thus the edge of
the ulcer is raised by the exuberant formation of cancer in and beneath
the boundary of skin : exuberance of the growth necessarily everts the
margin, which is too rigid to stretch ; and the margin thus raised and
everted is hard, nodular, and sinuous, because the growth under it, like
the primary cancer, is formed after a knotted tuberous plan. The base
of the ulcerated cavity is similarly hard and knotted, or covered with
hard, coarse, cancerous granulations. Lastly, when we cut through
such an ulcer, we divide a thick layer of cancer, infiltrated in the sub-
jacent tissues, before the knife reaches any normal structures.
It would be vain to try to describe all the various and dreadful forms
of ulcer that follow the acute inflammations and sloughings of scirrhous
cancers, or all the aggravations of the disease by hemorrhage from the
ulcerating surface, or by obstructions of the lymphatics or the veins.
As I pass by the effects of these accidents of the disease, in describing
its structures, so, much more, must I now. Only, I would state that
these are the events which produce, in cancerous patients, the most
rapid and the most painful deaths. When inflammation is averted from
it, a cancerous ulcer may exist very long, and make slow progress,
without extreme pain or disturbance of the health ; it may be no worse
a disease than the *' occult" cancerous growth ; and ten or more years
may pass with the health scarcely more impaired than at the beginning.
Sir B. Brodie* has related two such cases ; and I may add to them
one which I have lately seen in a cook, who has for eight years had
hard cancer of the breast. During five of these years it has been
ulcerating, and yet none of those with whom she lives is aware that she
is diseased.
Such cases of arrest of cancer are, however, very rare ; they are
* Lectures on Surgery and Pathology, p. 211.
550 SCIRRHOUS CANCER
only rare exceptions to the general rule of that progress towards death,
the rate of which is far less often retarded than it is accelerated by
such accidental inflammations of the cancer as I have already referred
to. Still more rare are the exceptions in which an ulcerated cancer
heals. Such cases, however, may be met with, especially among the
examples of the more superficial ulcer. The ulcers may be skinned over
(as any common ulcer usually is), and the cancerous mass beneath it
may waste and be condensed, so that the disease may be regarded as
obsolete, if not cured.
The conditions under which this healing and regress of the ulcerated
cancer may take place are, I believe, as yet quite unknown. In the
following case they seem to be connected with the development of
tuberculous disease, as if the patient's diathesis had changed, and the
cancer had wasted through want of appropriate materials in the blood.
I removed the breast of a woman 25 years old, including a large
mass of well-marked scirrhous cancer of three months' duration. She
appeared in good general health, and could assign no cause for the
disease. The progress of the cancer had been very rapid ; it had lately
affected the skin near the nipple ; and all its characters were those of
the acute form. The axillary glands had been enlarged and hard, bat
had subsided with rest and soothing treatment. Six months after the
operation, and after the patient had been for four months apparently
well, cancerous disease reappeared in the skin about the scar, and in
the axillary glands. In the skin it rapidly increased ; numerous tu-
bercles formed, coalesced, and ulcerated ; and the ulceration extended
till it occupied nearly the whole region of the scar, and often bled pro-
fusely. Thus the disease appeared progressive for twelve months after
its reappearance ; but at the end of this time the ulcer began to heal,
and in the next six months a nearly complete cicatrix was formed;
only a very small unhealed surface remained, like an excoriation
covered with a scab. The disease in the axilla, also, nearly subsided ;
one hard lump alone remained of what had been a large cluster of hard
glands. But even during and after the healing of the cancerous ulcer
she lost strength, and became much thinner, and at length, gradually
sinking, she died nearly two years after the operation, and six months
after the cancer had so nearly healed.
In the examination after death I found, in the situation of the scar
of the operation, a low nodular mass of the very hardest and densest
cancer, extending through the substance of the scar and the pectoral
muscle, and nearly all covered by thin scar-like tissue. In the axilla
was one hard cancerous gland, and in the liver were many masses of
cancer as dense and hard as that on the chest. In all these parts the
cancer structures appeared to be condensed and contracted to their ex-
treme limit.
The lungs contained no cancer, but were full of groups of gray suc-
culent tubercles and grayish tuberculous infiltration in every part ex-
PAIN. 561
oept their spices, where were numerous small irregular tuberculous
cavities. The other organs appeared healthy.
The contrast was very striking, in this case, between the appearances
of actiye recent progress in the tuberculous disease, and of the opposite
course in the cancerous disease found after death ; and I can hardly
doubt that, during life, the progress of the one had been at first coinci-
dent, and then commensurate, with the regress of the other.
But leaving, for the present, the questions of the relations between
cancerous and tuberculous disease, I would observe that this case illus-
trated the two modes of healing that may occur in cancer ; namely, the
formation of a scar over the ulcer, and the shrivelling of the cancerous
mass. The first appears to be accomplished according to the ordinary
method of the healing of ulcers : the second is probably similar to the
contraction and induration of deposits of inflammatory lymph. So far
as I know, the process of superficial healing has not been minutely ex-
amined in relation to the changes ensuing in the elementary structures
of the cancer. Only, one sees cuticle forming on the surface of appa-
rently cancerous granulations. In the process of shrivelling the can-
cerous mass becomes smaller, denser, drier, and harder; it contracts and
draws in more tightly the adjacent parts,; it yields no turbid *' juice,"
bat a thin serous-looking fluid may be scraped from it in very small
quantity. One finds in such fluid, sparingly distributed, cancer-cells
and nuclei, with molecular and granular d6bris-like matter; but (in the
breast) the chief mass of the shrivelled cancer seems to consist of the
proper tissues of the organs indurated and condensed. We cannot
doubt that, during such a change, cancer-cells and other elemental
structures are absorbed ; but the changes preparatory thereto are not,
I think, satisfactorily explained.*
Such may serve as a general history of the progress of a scirrhous
cancer in the breast. Let me add a brief notice of the pain, cachexia,
and some other of its accompaniments.
Among the many inconstancies in the life of cancers, none, I think,
is more striking than that which relates to the attendant pain. One
Bees cases sometimes, that run through their whole career without any
pain. In a case of deeply ulcerated cancer of the breast, the patient,
who had also a cluster of cancerous axillary glands, begged that the
disease might be removed, but only because it was '^such a terrible
sight." It had never once given her the least pain. In another case,
a patient, from whom a cancer involving the whole mammary gland was
removed, was quite unaware of any pain or other affection in her breast
till, a few weeks before the operation, some of her friends observed its
diminished size. The largest hard cancer of the breast that I have yet
removed was equally painless. Another patient, who died with rapidly
* The whole process is minutely discussed by Virchow, in his A/chiv, B. i, p. 185, etseq.
652 SCIRRHOUS CANCER.
progressive and ulcerated cancer, had not a pain in its two years*
duration'.
On the other hand, we sometimes meet with cases that quite exem-
plify the agony which is commonly regarded as the constant accompa-
niment of hard cancer. In such a case the patient could *' wish herself
dead," for the sake of freedom from the fierce anguish of her pain, —
pain as if a hot dart were thrust swiftly through her breast, or right
through her chest, — pain, starting with a sudden pang, and then seem-
ing to vibrate till it fades out slowly ; or sometimes more abiding pain,
likened to the burning and scalding of hot water or of molten lead.
With such resemblances as these do patients strive to describe the
agonies, which are indeed beyond description, and of which the peculiar
intensity is perhaps best evidenced by the fact, that the sufferers almost
always thus liken them to some imaginary pain, and not to anything
that they have felt before. The memories of those who have suffered
even the pains of child-birth supply no parallel of that which is now
endured ; the imagination alone can suggest the things with which it
may be compared.
Now, although both these classes of cases be exceptions from the
general rule concerning the painfulness of cancer of the breast, yet they
are interesting, both for their own sakes, and because they illustrate
the nature of the pain attending tumors ; they show that it is, in great
measure, independent of the merely mechanical condition of the parts ;
that it is due not to pressure on the nerves, or to their tension or dis-
placement, but rather must be considered as a subjective sensation, a
neuralgia, due to some unknown morbid state of nerve-force. That
this is so is nearly sure from the fact, that if we compare the most
painful and the least painful cancers with each other, we may find their
structure and relations exactly similar. Any of the forms that I have
described may in one case be attended with intense pain, in another
may exist without discomfort. They may present no other difference
than the immense difference of painfulness.
However, as I have said, both the very painful cancers and those
that are always without pain are exceptional cases. The more general
rule seems to be : (1) that in the early part of its course (for instance,
in ordinary cases for the first year or year and a half), the hard cancer
of the breast is either not painful at all, or gives only slight and occa-
sional pain, or is only made painful by handling it ; (2) that during
this time its pain has usually no peculiar character ; is not generally
lancinating, but more often, and especially after manipulation, is dull
and heavy ; (3) that after this time the cancer becomes progressively
more painful, and the pain acquires more of the darting and lancinating
character ; (4) that the pain is generally increased when the cancer
grows quickly, and more constantly when it is inflamed or ulcerating,
or about to slough ; (5) that the pain is yet more intense when the
MULTIPLICATION. 553
cancer is.progressiyely ulcerating, and now adds to its lancinating cha-
racter^ or sabstitutes for it, the hot burning or scalding sensation.
With the advance of the local disease the signs of general disorder
of the health usually increase ; and the cancerous '* cachexia," which
may at first have been absent or obscure, is established. It would be
very difficult to describe this state exactly, and much more so to analyze
it. The best description of its most frequent characters is, I think, that
by Sir Charles Bell :* " The general condition of the patient is pitiable.
Sufiering much bodily, and everything most frightful present to the
imagination, a continual hectic preys upon her, which is shown in in-
creasing emaciation. The countenance is pale and anxious, with a slight
leaden hue ; the features have become pinched, the lips and nostrils
slightly livid ; the pulse is frequent ; the pains are severe. In the hard
tumors the pain is stinging or sharp ; on the exposed surface it is burn-
ing and sore. Pains, like those of rheumatism, extend over the body,
especially to the back and lower part of the spine ; the hips and shoulders
are subject to those pains. Successively the glands of the axilla and
those above the clavicle become diseased. Severe pains shoot down the
arm of the affected side. It swells to an alarming degree and lies im-
movable.
*' At length there is nausea and weakness of digestion : a tickling
cough distresses her ; severe stitches strike through the side ; the pulse
becomes rapid and faltering; the surface cadaverous; the breathing
anxious; and so she sinks."
This vivid sketch is generally true of, perhaps, a majority of the
cases of hard cancer of the breast ; but I doubt whether any one of the
signs of cachexia here indicated is constantly present. Even emacia-
tion is not so ; for many die, exhausted by the suffering and discharge,
in whom fat is still abundant, or appears even increased about the
cancer itself. This want of constancy adds greatly to the difficulty of
analyzing the phenomena of the cachexia. We can see little more than
that they include two mingled groups of symptoms : of which one may
be called ^^ primary," depending on the increasing morbid and peculiar
cancerous condition of the blood, and the other "secondary," depend-
ing on the local disease and the effects produced on the blood by its
pain, discharge, hemorrhage, and various accidents. In the confusion
of symptoms thus arising, analysis seems impossible.
The last concomitant of the scirrhous cancers of the breast, that I
need now speak of, is their multiplication ; but I will here only enume-
rate the methods in which this may happen ; for its explanation belongs
to the general pathology. These, then, are the methods :
First, and most frequently, the disease extends to the lymphatic ves-
* Medico-Chirargical Transactions, xii, 223.
36
554 SCIRRHOUS CANCER OF THE BREAST.
sels and glands ; or to their contents ; for it seems most probable that,
as Mr. Simon has suggested, its progress is along the continoity of the
lymph from the breast to the glands.
(2) Next, I think, in order of frequency, are the maltiplications of the
cancer in the same region ; not, indeed, in the same gland, but in the
skin and muscles near it, and then in areas gradually widening round it.
(8) It is less frequent for the scirrhous cancer to appear secondarily
in the similar tissue of the opposite breast. Indeed, its multiplication,
if it may be so considered, is less frequent in this direction than in that
of some organs of more different texture, especially the bones, the liver,
and the lungs. These, among parts distant from its primary seat, are
by far the most frequent seats of secondary disease ; but with these, or,
much more rarely, alone, nearly every tissue has been found affected.*
The structures of many examples of these secondary cancers are
already described (p. 533, &c.) It is often said that the cancers which
appear as secondary to the scirrhus of the breast are of the medullary
kind ; an error which I think must have arisen from the belief that the
scirrhous cancer is always fibrous. I have already explained that it
very rarely is so, and only appears to be so when it grows in parts con-
taining fibrous tissue ; and that what has been generally deemed the
fibrous structure of the cancer is usually that of the organ in which it
is seated. The secondary cancers are, usually, in all points conformed
to the primary, and consist, like them, essentially of cells compacted
into a hard mass. They may appear fibrous when growing in fibrous
organs: but inasmuch as their more usual seats are in organs that
naturally contain little or no fibrous tissue, they are more commonly
formed of cell-structures alone. The change from hard to soft cancer
is rare ; it may, however, take place, especially in the latest growths ;
and it is the best illustration of the aflSnity between the two forms of
the disease.
To end this history of the scirrhous cancers of the breast, I must
speak of their duration. There is a striking contrast between the cer-
tain issue, and the uncertain rate, of their progress. Cases are on
record in which life has been ended in four months, and others in which
it has been prolonged to twenty-five years; but I am not aware of a
single clear instance of recovery ; of such recovery, that is, as that the
patient should live for more than ten years free from the disease, or
with the disease stationary. The nearest approach to this that I have
yet seen was in the case of a woman, from whom, at 51 years of age, I
removed a cancerous breast of two years' duration, and numerous axil-
lary glands. She lived and worked hard for llj years without any
apparent return of the disease, and died with progressive muscular
atrophy of the tongue and pharynx. After death, no trace of cancer
* M. Lebert has given a table of the relative frequencies of secondary cancers in difle^
ent organs afler primary disease in the breast. It is drawn from 23 autopsies. Mr. Birkett
has given a similar table of 37 cases examined after death.
MULTIPLICATION. 555
was to be found, except a few yer j hard white masses in the liver and
gastro-hepatic omentum.
The average duration of life, from the patient's first observation of
the disease, is a little more than four years. In 66 cases, tabulated
without selection, I find it something more than 49 months.'*'
Among 61 of these, 7 died in between 6 and 12 months.
7 ** 12 •* 18 **
8 " 18 « 24 «
10 « 24 « 30 «
2 " 30 " 36 «*
12 « 3 « 4 yeare.
6 ** 4 •* 6 "
3 " 6 »* 8 "
1 « 8 « 10 "
5 " 10 « 20 "
The cases are too few to allow of many conclusions ; but they suffice
at least to show that the average duration of life in these cancerous pa-
tients would afford a wrong estimate of the probable duration of life in
any single case ; since the number who live beyond the average is far
less than that of those who die within it, and the mean average is raised
by the lives of those few* who survive long periods.
It seems at present impossible to estimate many of the conditions
which determine the duration of life ; but none among them seems more
weighty than the age at which the disease commences. There are,
indeed, many exceptions to the rule, yet, on the whole, the earlier the
disease begins the more rapid is its course. Thus, among those who
lived not more than 18 months, I find that the average age at which the
disease was first observed was 43 years. Among those who lived be-
tween 18 and 86 months, it was 51 years ; and among those who lived
between 8 and 8 years, the average at the commencement of the disease
was 56.7 years.f
In all the cases from which the foregoing deductions were made, the
disease ran its course uninterrupted by operative treatment.
In 47 cases, in which the cancer was once or more removed by opera-
tion, the average duration of life, after the first observation of the dis-
ease, was again something more than 49 months. I believe, therefore,
* I mj ** something more/' because I have reckoned in the cases of five patients who are
stiU living, more than 49 months from the first observation of the disease. In the table on
the next page six similar cases are reckoned with those from which the general average is
derived. Of the patients already dead, the average duration was, for those in this table,
49.36 months; Ibr those in the next table, 48.9 months. The difference is far less than I
believed it to be when the lecture was delivered : I was deceived at that time by using too
small a number of cases, and a table containing some cases that were recorded only because
tbef were examples of rarely long life.
f The average for those who lived more than 8 years was only 45 years. But this will
not materially invalidate the rule as stated above, if, as I suspect, these long lives owe their
tmosiial duration to something interfering with the more normal progress of the disease ; and
if| at ia also probable, the deaths from cancertf commencing in those whose average age is
near 00 are often prevented or accelerated by the other .diseases which destroy so large a
piopoftion of persons living to that age.
566 SCIRRHOUS OANCBB OF THB BREAST.
that the removal of the local disease makes no material difference in the
average duration of life ; but if the following table be compared with
that on the preceding page, it will seem probable that the course of the
more rapid cases is retarded by the operation. Among 41 of those
patients who are already dead, —
4 di
ed in between
1 6 and 12 months.
4
u
12
u
18
i(
2
K
18
u
24
M
5
tt
24
tt
30
U
3
U
30
u
36
M
11
u
3
tt
4
years.
8
tt
4
tt
6
tt
2
u
6
tt
8
u
1
t(
8
((
10
u
1
u
10
tt
20
tt
It would seem, I repeat, as if the course of cancerous disease, that
otherwise would be very rapid, were retarded by the removal of the
growth ; for^ while in some respects the two tables closely correspond,
it may yet be noticed that the proportion of those who die within two
years is 86 per cent, of those in whom the disease is allowed to run its
course, and only 24 per cent, of those from wh^om the growth is once or
more removed. The number of cases from which this is concluded is
indeed small ; but other facts might lead us to expect the same, espe-
cially that in general the most rapidly fatal cases are those in which the
local disease has the greatest share in the death.'*'
The constitutional part of the cancerous disease, little, if at all,
affected by the removal of the local part, manifests itself by the recur-
rence of cancerous growths in or near the seat of operation, or in the
lymphatics of the breast, or in some more distant part. In 74 cases,
comprising 21 collected by M. Lebert, and 53 by myself, the periods of
recurrence after the operation were as follows :
Between
1 and
3 months in
23
u
3
tt
6
u
22
tt
6
u
9
M
8
((
9
(I
12
tt
6
u
12
u
24
i;
7
u
2
tt
3
years in
3
u
3
tt
4
it
1
((
4
tt
6
((
2
tt
6
ti
8
t(
2
u
tt
u
it
tt
u
ti
tt
^ Tables published by Mr. Baker (1. c.) seem to prove that, by a better selection of cases
for operation than had been made in the instances from which the above tables were con-
structed, much better results may be obtained. Thus in 84 cases, of which by far the greater
number occurred aAer the publication of the first edition of these lectures, and on which oo
operation was performed, the average duration of life was 43 months ; and in 62 cases on
which operations were performed, the average was 55.6 months. Mr. Sibley's tables Id'
dicate a still greater difference : the average in cases of removal of the breast being 56.6
months, and of non-removal 32.25 months. (Med.-Chir. Trans., vol. xlii.) To the same
better selection of cases it may probably be referred that» according to one of Mr. Baker's
tables, only 42 per cent, of the recurrences occurred within six months of the operation, in-
stead of the 60 per cent shown in the text
EFFECTS OF REMOVAL. 557
Neither of us has yet met with a case in which recurrence was de-
layed beyond eight years.*
The table confirms the view that the removal of the local has little
influence on the constitutional element of the disease ; for eyen if we
belieye that many of the cases, reported as recurrences between 1 and
8 months, were examples of continuous, rather than of recurrent, local
disease, still the small proportion of cases in which recurrence was de-
layed more than twelve months after the operation might suggest the
belief, that after an operation the constitutional disease continues and
increases, till it manifests itself in recurrent local disease, in about the
same time as it might have appeared in some secondary cancer, if 'the
operation had not been performed.
The recurrent local disease appears generally to be less intense than
the primary. This is probable, both from the fact mentioned at page
556, respecting the smaller proportion of rapidly fatal cases in those
submitted to operation, and from the fact that when recurrent cancers
are removed, the second recurrences sometimes ensue more slowly than
the first did. In 12 cases in which recurrent cancers of the breast
were removed, I find that the period of second recurrence, t. e, the
interval between the second operation and the reappearance of the
disease, was
Between 1 and 3 months in 4 cases,
u 3 u 5 u 3 a
« 6 *• 12 « 1 **
" 2 " 3 years in 2 «
tt 6 « 7 ** 2 **
And, among these late-recurring cases, is one in which the first re-
currence was after 24 months, the second after 60 ; another of first
recurrence in 12 months, and second in 84 ; and another of first recur-
rence in 2 months, and second in 24.
It is believed by some that the cancer of the breast (and they would
say the same of other cancers) is in the first instance a local disease ;
and that the constitutional disease which is manifested by recurrence
after operation, or by multiplicity of cancers, or by cachexia, is the
consequence of the slowly acting influence of the local disease.
If this opinion were true, we ought to find that the average interval
between removal of the disease and its recurrence bears an inverse pro-
portion to the time of duration of the cancer before removal. No such
proportion, however, exists : nor does it even appear that recurrence
is, on the whole, later after early, than after delayed, operations. The
following table shows the times of recurrence in 56 cases, in which the
* Since tbe first edition, a patient has lived 9} years after operation without any sign of
feeorrence, and perhaps the case mentioned at p. 554 may be considered as another instance
of reciiReiiee delayed beyond eight years.
568 SCIRRHOUS CANCER OF THE BREAST.
removal of the cancer was effected within yarious periods, from three
months to four years, after its first appearance :
Time of Opentkni.
Tims of RaeosrsMti.
Within
Between
Blore than
Vou
6 months.
6 A 12 months.
la months.
Om
Under 3 months,
. 4
2
2
s
Between 3 and 6 months,
. 5
2
2
9
a 6 " 12 "
. 5
4
5
14
a 12 "24 «
. 9
1
3
13
« 24 "48 «
. 7
3
2
12
The following table shows that the duration of life is not greater
after early than after late operations : but this is, doubtless, because
the most acute cancers are, on the whole, the most early removed :
ATerafe dnntlon MnmlMK
Time of Operation. of lift after the of
operation. Oases.
Under 3 months, 20 months. 4
Between 3 and 6 months, 12 " 6
« 6 " 12 « 39 « 8
** 12 « 24 « 17 " 8
« 24 " 48 « 21 « 5
Lastly, I can find, in the cases I have collected, no confirmation of
the received (and possibly true) opinion, that when some of the axillary
lymphatic glands are cancerous, and are removed with the cancerouB
breast, the recurrence of the disease, and its fatal termination, are more
speedy than after operations in which the breast alone is removed, the
glands appearing healthy. In 20 cases of removal of the breast alone,
the average time of recurrence was eight months, and that of death
twenty-four months, after the operation : while in 10 cases of the re-
moval of the breast with some axillary glands, the recurrence ensued,
on an average, in thirteen months, and the death in twenty-four months,
after the operation.
I find as little cleariy recorded evidence for the similarly unfavorable
opinion generally entertained of the efiects of the removal of cancers
adherent to the skin, or already ulcerated. I would be far from hold-
ing that these opinions are incorrect ; but their truth is not yet proved;
and it is not supported by such cases as I have been able to collect
The recurrences and deaths after these ''unfavorable'* cases are indeed
sure and speedy ; but I am not yet clear that they are more so than
those are which follow the operations that are undertaken in some of
what are deemed the most favorable cases.
The foregoing facts, relating to the influence of the removal of can-
cerous breasts on the progress of the disease, and on the duration of
life, may be considered from two points of view, — the pathological and
the practical. Mere pathology may study these operations as so many
EFFECTS OF REMOVAL. 559
experiments for determining the mutual influences of the local and the
constitutional elements of the cancerous disease; or, the questions
entertained by some respecting^ their priority ; or, the share taken by
each in destroying life. I trust that the tables I have given may be of
some avail for the settlement of these and other similar questions to
which I shall again refer in the concluding lectures. But at present,
few of the facts, which mere pathology can gather from inquiries such
as these, are sufficiently clear or pronounced to serve for guidance in
the practice of surgery, in which we have to deal with single cases, not
with many at once, and in which each case presents many questions
that cannot yet be solved by general statements.
In deciding for or against the removal of a cancerous breast, in any
single case, we may, I think, dismiss all hope that the operation will be
a final remedy for the disease. • I will not say that such a thing is im-
possible ; but it is so highly improbable, that a hope of its occurring in
any single case cannot be reasonably entertained.
The question, then, is, whether the operation will add to the length,
or to the happiness, of life. The conclusion from the foregoing tables
might be that the length of life would be the same, whether the local
disease were removed or not. But such a conclusion cannot be uncon-
ditionally adduced for the decision in a single case. The tables do not
include cases in which the operation was fatal by its own consequences :
yet these are not few. In 285 operations for the removal of cancerous
and other diseased breasts, I find 23 deaths : and probably this mor-
tality of 10 per cent.2is not too high an estimate, — at least, for the results
of hospital practice. We have to ask, therefore, whether it is probable
that the operation will add to the length or comfort of life, enough to
justify the incurring this risk from its own consequences.
I cannot doubt that the answer may be often affirmative. 1. In cases
of acute hard cancer the operation may be rightly performed : though
speedy recurrence and death may be expected, its performance is justi-
fied by the probability (see p. 555) that it will, in some measure, pro-
long life, and will save the patient from dreadful suffering. 2. On
similar grounds, the operation seems proper in all cases in which it is
clear that the local disease is destroying life by pain, profuse discharge,
or mental anguish, and is not accompanied by evidences of such cachexia
as would make the operation extremely hazardous. 8. In all the cases
in which it is not probable that the operation will shorten life, a motive
for its performance is afforded by the expectation that part of the re-
mainder of the patient's life will be spent with less suffering, and in
hope, instead of despair ; for when they are no longer sensible of their
disease, there are few cancerous patients who will not entertain and
enjoy the hope of long immunity, though it be most unreasonable and
not encouraged.
On the other side, there are many cases in which the balance is clearly
against the operation. 1. In well-marked chronic cancers, especially
560 SCIRRHOUS CANCER OF THE BREAST.
in old persons, it is so little probable that the operation will add to
either the comfort or the length of life, that its risk had better not be
incurred. These are, indeed, the cases in which the operation may be
longest survived ; but they are also those in which, without operation,
life is most prolonged and least burdened. 2. In cases in which the
cachexia, or evident constitutional disease, is more than proportionate
to the local disease, the operation should be refused : it is too likely to
be fatal by its own consequences, or possibly by accelerating the pro-
gress of cancer in organs more important than the breast. On similar
grounds, and yet more certainly, it should not be performed when there
is any reasonable suspicion of internal cancer. 3. If there be no
weighty motives for its performance, the operation should be avoided
in all patients whose general health (independently of the cancerous
diathesis) makes its risk unusually great ; in all, for example, who are
very feeble, very fat, over-fed, intemperate, or in any of those condi-
tions which make persons unfavorable subjects for surgical operations.
The above rules leave unconsidered a large portion of the cases of
hard cancer of the breast ; and I fear that, at present, no other state-
ment can be made concerning the cases which do not fall within such
rules as these, than that each must be decided, by weighing the proba-
bility that the operation will prove fatal, or, by weakening the patient,
will accelerate the progress of the constitutional disease, against the
probability of its adding to the comfort, and thereby to the length, of
life. The first of these probabilities must be estimated by the same
general principles (vague as they are) by which we reckon the dangers
of all capital operations : the estimate of the second may be, I hope,
assisted, though it cannot be settled, by the evidence collected in the
foregoing tables. In every case we should keep in view the twofold
method of destruction by this disease. It may destroy life by its con-
sequences as a local disease ; or by its primary and specific cachexia,
which may be progressive independently of the local afi^ection. Usually,
indeed, its local and constitutional parts mutually afiect and aggravate
each other, and both contribute to the fatal issue ; but, since they do
not always contribute in the same proportions, our object should be to
ascertain, in each case, which will contribute most, — the local disease,
which the operation can remedy, or the constitutional, which, if at all
affected by the operation, may be made more intense.
MBDULLART GANGER. 561
LECTURE XXXL
MEDULLARY CANCER.
PART I. — ANATOMY.
From the long list of names which Dr. Walshe, with his usual pro-
found research, has found assigned to this disease, I select that of Mb-
DULLART Oancbr, because it has been sanctioned by the longest usage
and by many of the best pathologists. It is true that the term *^ medul-
lary" is yague and unmeaning; yet even this seeming defect may have
some advantage, since, after long custom, we may now employ the
word, as we do inflammation, cancer, and many others, without any
reference to their original meaning, and, therefore, without any danger
of too much limiting our thoughts to the likenesses which they express.
The very precision and fixity of such terms as encephaloid, cerebriform,
cephaloma, and the like, are objectionable, by directing the mind to a
single character of diseased structures, and that an inconstant one ; for
the likeness to brain is observable in only a portion of the tumors to
which the names of brain-like and its synonyms are applied.
The boundaries of the group of medullary cancers can be only
vaguely drawn ; for, although, on the whole, and as a group, they have
peculiarities both of structure and of history, which sufficiently distin-
guish them from the scirrhous and other cancers, yet, define them by
whatever character we may, a series of specimens might be found filling
every grade between them and each of the other chief forms. The
term "soft cancer,*' often applied to them, expresses their most obvious,
though not their most important, distinction from the scirrhous or hard
cancers, and, used comparatively, it might, for the present, suffice for
the definition of the group. But, in the group thus defined, there are
included many forms that appear widely difierent from each other ; and
there is, as Rokitansky has well said, no disease of which the examples
present more deviations from any one cardinal character. It might be
right to arrange the examples of some of these deviating forms under
distinct titles ; but, at present, it may be more useful to make no other
division of the group, than into such as may be called, respectively,
toft and^rw medullary cancers. In any large series of specimens, the
softer kinds would constitute about two-thirds, the firmer about one-
third, of the whole number. The former would include such as are de-
scribed as encephaloid, brain-like, milt-like, pulpy, placental, &c.; the
latter would be such as have been called mastoid, solanoid, nephroid,
apinoid, &c.*
* I believe, alao, that many examples of ** albuminous sarcoma** have been firm medul-
kuy cancert.
KBDOLLABt OANOBB.
Certain transitional specimens would be found in the Mri««, wluck
might be arranged in either division, or betwoen the two; Init thwri,
though they may prove that there is no specific distinction betwcta lit
two chief divisions, do not invalidate the utility of apeaking of thei
separately.
The medullary cancers, whether soft or firm, may grow either m te-
parable tumors or as infiltrations. In the former oon<IitJon, tiiej an
most frequent in ibe intermuscular and other spaces in the limbs, b At
testicle, the mammary gland, and the eye: rarely, they »re thw ttaai
in the bones. In the latter condition, they most frequently oeeapj tJw
substance of the uterus, the digestive canal, the serous menbruMi, iW
periosteum and the bones.
We have, herein, the first point of contrast, in addition to that rf
their consistence, between the medullary and the scirrhooft euMfriL
The latter are almost always infiltrations of natural part«: the focwr
appear, in nearly equal frequency, as iDfiltratious, or M diatiMl
growths, of cancer-substance,
The contrast is equally marked between them in regard to tluir f^
spcctive seats and allocations. Of every 100 primary hard cuuen,!
believe that not less than 95 would he found in the breast ; and Am
is no other organ in which tbey are not very rare. But, amon^ 101
tabulated instances* of medullary cancer in external parts, the aeal »l
primary disease was in the
Te«<lcle, in 99 cnn
Bonvs (moat rreqnemljr in ihfl femur), .' . . . " 91 *
Limla [opeciallj in ibo inlermutoolat gpmpu), ■ . " 10 *
EjreUllororbil, ■ 10 •
Breati, •?"
Walla of ihe ohMi or KhlomeD • 5 *
Lympbaijoi, "4"
Various otbei pun*, '•*
lOS
Let me now, for general examples, describe such soft mednllaij !■■
mora as often occur in the intermuscular spaces of the limbs or Insk.
To the touch they present a peculiar softness, or a deceptive loM
of the slow fluctuation of some thick liquid ; so that, even to the W0
experienced, their diagnosis from collections of fluid is often '
and ihe achievement of experience in relation to tliem ia
than knowledge.
In shape, these tumors are commonly round, oral, or
* 1 1 need banllf be nid ihal ihis table, conlaining no oaiea of ipedBnaif MaMrkt
ulera* ot dher intemal organs, i> nol iniended lo prove anjrlUnf aonnnwili^ 4M Mhl
frequDiiey of Ibe diseDw in pacb psct of ibe boilf . I know no recotil* br wkiok Him
be proTcd. In on)/ purpotn are, lo thaw ilie ooDttaM belwe«n m«)alla(7 aod •
GBKEBAL BTBUOTURB AND RELATIONS. 568
fitting the adjacent parts. But they may be yariousi j lobed ; and when
they are so, these following things may be noticed in them, as well as
in ihe firmer kinds. (1) Their lobes are peculiarly apt to extend into
muscolar and other interspaces, far away from their chief mass. Thus
(as I haye seen) in the foot, they may track through the interosseous
metatarsal spaces, or between bones of the tarsus ; or, about the hip
or knee, portions may extend deep down to the immediate ooyerings of
the joint ; or from behind the ankle-joint, they may reach, with the
flexor tendons, far into the sole of the foot. (2) Thus deepening as
they grow, parts of these tumors may acquire unexpected deep-seated
attachments. It is frequent to find them so attached in the neck, eyen
when, in their beginning, they were easily moyable tumors, or such as
patients call *' kernels." (8) In the same extension, they are much
more apt than other tumors are to grow around, and completely inclose,
important yessels and neryes. I haye thus seen, in one case, the phrenic
nenre, in another the pneumogastric, in another the femoral artery, in
others the carotid artery and jugular yein, passing right through medul-
lary cancers which, at first, appeared freely moyable and not deeply
fixed, and eyen now had no characters of infiltration.
The parts around a separable medullary cancer are generally only
extended, as they might be around an innocent tumor. They are usually
not contracted, or adherent, as those next to a hard cancer are. Even
such a tissue as the glandular substance of the testicle may be cleanly
separated from the surface of a medullary cancer, around which it has
been stretched. Sometimes, howeyer, the parts near the principal tu-
mor contain smaller detached growths ; and more rarely they are infil-
trated with cancer.
When a distinct capsule exists around a medullary cancer, it is
usually composed of connectiye tissue, forming a yery thin layer, from
the interior of which partitions may pass, intersecting the substance of
the tumor, or investing its several lobes. Generally, such a capsule
contains nimierous tortuous bloodvessels ; and is tensely filled, so that,
as soon as it is cut, the tumor protrudes, or, when very soft, oozes out,
like a thick turbid fluid. It is, usually, easy to separate the capsule,
or part of it, from the surrounding tissues ; but it may be closely ad-
herent, and, I think, generally is so in the cases of medullary cancers
in the breast.
In section, the soft medullary cancers usually appear lobed ; and the
partitions between the lobes, derived from the investing capsule, are
often so complete that they may appear like separate cysts filled with
endogenous growths. The lobes are of various sizes and shapes,
through mutual compression, and they may even seem very differently
constructed.
The material composing these cancers (when not disordered by the
effects of hemorrhage, inflammation, or other disease) is a peculiar, soft,
dose-textured substance, having very little toughness, easily crushed
564 SOFT MBDULLART CANCBB.
and spread out by compression with the fingers. It is yery often truly
brain-like, most like foetal brain, or like adult brain partially decom-
posed and crushed. Many specimens, however, are much softer than
brain ; and many, though of nearly the consistence of brain, are unlike
it, being grumous, pulpy, shreddy, or spongy, like a placenta, with fine
soft filaments. Very few have a distinct appearance of fibrous or other
regular structure.
In color, the material may be white, but most commonly, when the
cancer is fresh, it is light gray (like the grayness of the retina after
death). The tint is usually clear ; it is in many cases suffused with
pale pink or lilac, or with a deeper purple ; and, in nearly all, is varie-
gated with effused blood and full bloodvessels, whose unequal abun-
dance in different parts of the tumor produces a disorderly mottled ap-
pearance. Masses of bright red or ochrey substance also, like tubercle,
are often found in or between the lobes, as if compressed by them, while
withering and drying in the midst of their growth.
When pressed or scraped, the soft medullary cancers yield abundant
^* cancer-juice,*' a milky or cream-like, or some other turbid, material,
oozing or welling up from their pressed mass. There is no better rough
test for the diagnosis of medullary cancers than this is; and the sub-
stance thus yielded is generally diffusible in water, making it uniformly
turbid, not floating in coarse shreds or fragments.
When the greater part of the softer and liquid substances are thus
pressed out, there remains a comparatively small quantity of tissue,
which appears filamentous, with abundant bloodvessels, and, to the
naked eye, is spongy and flocculent, like the tissue of a placenta. This
is the so-called " stroma'* of the cancer; and it differs from that which,
in the hard cancers, has been so named (p. 531), in that it is not part
of the tissue in which the cancer has its seat, but is probably formed
during the growth of the cancer, and is as truly part of the cancer as
the cells and other corpuscles are.
Such are the most general or normal characters of the soft medullary
cancers. It would be vain to attempt to describe all the varieties to
which they are subject by the mingling of cysts within or on the sur-
face of their mass ; by hemorrhage into their substance ; by inflamma-
tion ; and by the various degenerations of their proper substance, of
the extravasated blood, and of the inflammatory products. There are,
I think, no other examples in which the diseases of the products of dis-
ease are so frequent, so various, or so confusing as in these.
It is in the medullary cancers alone that the bloodvessels have been
minutely studied; and in these alone that it is easy to distinguish the
vessels of the cancer itself from those of the organ in which it is seated.
M. Lebert and his colleagues have made numerous injections, display-
ing arteries, capillaries, and veins, arranged in networks of various
closeness, in the substance of medullary cancers of the ovary, omentum,
uterus, and other parts. They have thus disproved the belief that the
VASCULARITY. 566
yascular system of these tumors is exclusively either arterial or venous.
I may add, that the minute bloodvessels, though, in proportion to their
sixe, they are thin-walled and easily torn, have the same structures as
those in other new-formed parts.*
In some medullary tumors we may notice a remarkable abundance of
even large bloodvessels. Next to the proper cancer-corpuscles, they
may appear to be the chief constituent. The cancer that contains them
^4 thus appear in many respects like an erectile tamor, and may often
vary in size according to the fulness of its bloodvessels. (See p. 576,
note.) When the bloodvessels are chiefly arterial the whole mass of the
tumor may have a soft, full pulsation — ^a condition which seems pecu-
liarly apt to be found when the tumor is in part imbedded in, or sup-
ported by, bone, and in part held down by fibrous tissue, such as that
of the periosteum.!
To the same abundant vascularity of these tumors we may ascribe
not only their liability to internal apoplectic hemorrhage,;}; but the
great bleedings that may ensue when they protrude through ulcers, or
are wounded. I have twice seen the difficulty of distinguishing a
medullary cancer of the testicle from an hsematocele enhanced by the
fact, that when the swelling was punctured with a trocar, blood flowed
in a full stream through the canula, and continued so to flow till the
eanula was withdrawn. The size of the swelling was not diminished, as
that of an hsematocele would have been, by the abstraction of the blood ;
and in both cases it proved to be a large medullary cancer, very vascu-
lar and very soft. So, when such tumors are cut into in the limbs, the
vessels that bleed are far larger and more numerous than in any other
tumor, except the erectile.
The vessels, moreover, often appear defective in muscular power ;
for, as Mr. Hey§ noticed, the bleeding from them scarcely decreases
even when a tourniquet compresses the main artery of the limb. It is
as if they could not contract so as to close themselves, even when the
force of the blood is diminished to the amount with which it traverses
the anastomosing channels. Lastly, we may connect with the great
vascularity and rapid growth of these soft tumors, the large size of the
veins near them ; though this is not peculiar to them, but is found, I
think, with nearly all tumors that grow rapidly and to a large size.
Lymphatics have been injected in two specimens of medullary cancer
* Dr. WesthofT, in a thesis ** Mikrosk. Onderzockingen over de Ontaarding von Aderen
eD Zemnven in Kanker," 1860, which is analyzed in the Dublin Quarterly Journ., Nov.,
1860, makes it probable that the impossibility of injecting veins in some cancers is due to
tbeir being filled with cancerous matter, which stops the injection aAer it has traversed the
capillaries.
f See Mr. Stanley's paper on the ** Pulsating Tumors of Bone," in the Med.-Chir. Trans^
vol. xzviii, p. 903.
{ It is chiefly to the medullary tumors, changed by internal, and prone to external,
hemorrhage, that the name of fungus hsematodes has been applied.
S Observatkms in Surgery, p. 258.
566 MEDULLARY CANCEROUS INFILTRATION OF BONB.
of the stomach and of the liver, by Schroeder van der Kolk.* In both
instances the vessels passed into the very substance of the cancer. Of
nerves, I believe that none have been found in these or in any other
cancers, except such as they have involved in their growth.
The same structures which alone form the separable medullary can-
cers may be infiltrated among the natural structures of parts. Thus
infiltrated, the natural structures are expanded and rarefied ; some-
times, indeed, they seem to be, in a measure, thus changed, even before
the cancerous material is deposited among them.f Finally, most of
them disappear, as in the infiltrations of scirrhous cancer ; and the
cancerous mass may now seem like a separately growing tumor ; or,
when its material is very soft, it may appear as a quantity of creamy
liquid, collected like the pus of an abscess, in a defined cavity.
Exceptions to the general rules of the wasting of the infiltrated tis-
sues are often observed in the fibrous tissues and the bones ; both these
may increase during soft cancerous infiltrations.
Medullary cancers may be found in the articular ends of bones, form-
ing distinct tumors, around which the walls of the bone are expanded in
a thin or imperfect shell. But more commonly the cancer is infiltrated.
In these cases, it usually occupies, at once, the cancerous tissue, the
wall of the bone, and the periosteum : and it seems probable that the
disease begins simultaneously in all these parts ; or, at least, that when
they are aifected in succession, it is not generally by extension from
one to the other. Hence we commonly find that a tumor surrounds the
bone, or, in the case of a flat bone, covers both its surfaces ; and that
the portion of bone thus invested is itself infiltrated with cancer, which
is collected most evidently, but not exclusively, in its cancellous tissue.
When a medullary tumor thus surrounds a long bone, it is usually of
unequal thickness : when both surfaces of a flat bone are covered the
tumor is usually biconvex lens-shaped, and is, on both surfaces, of
nearly equal extent.
The periosteum may seem to be continued over a medullary cancer
thus placed ; but is really, with the exception of a thin outer layer, in-
volved in it, and intersects its substance. The intersecting portions of
periosteum chiefly traverse the exterior tumor, extending from the layer
which invests its surface to the wall of the bone. They form brancluDg
and decussating shining bands, which to the microscope present a per-
fect fibrous tissue, infiltrated with the cancerous materials. They may,
also, be much increased by growth, so as to give the section of the
tumor an appearance of " grain," or of a tissue with fibres set vertically
on the bone. Or, the periosteal tissue thus growing may ossify. In
this event, it forms, in a large majority of cases, a light, spongy, and
friable growth of bone, which is like an internal skeleton of the cancer.
Most of the specimens of " spongy*' or " fungous'' exostoses are such
* Lespinasse: De vasis novis pseudomembranarum, 1S42, p. 41.
f Walshe, 1. c, p. 555.
MEBULLABT CAKCBROUB INFILTRATION OF BONE. 567
skeletons of cancers, examined after the maceration and removal of all
the morbid structures that filled their interspaces. The new bone is
often formed in thin plates and bars or fibres, the chief of which extend
outwards, at right angles to the surface of the bone on which they grow ;
they may pass deeply into the substance of the cancer, but they seldom
reach its outer surface : no medulla is formed with them ; and they
sometimes form a denser and harder tissue, like that which belongs to
the osteoid cancers (see p. 483).
In the walls, or compact substance, of the bone thus inclosed by can-
cer, it is common to find the laminaa separated by cancerous deposit,
mingled with a ruddy, soft material like diploe. In other cases, the
structure of the walls is rarefied, and converted into a light, soft, and
porous or finely spongy tissue, whose spaces contain cancer-structures.
The Haversian canals, also, may be enlarged ; cancerous matter being
formed within them. Sometimes, a peculiar appearance is derived from
an unequal separation of the laminae of a bone's walls ; large spaces
being found between them, like cysts, which may be filled with blood
or softened cancer.
Lastly, in the diploe or cancellous tissue, a corresponding state exists.
The soft cancerous material excludes the medulla, and, commonly, its
•formation is attended with a disturbed growth of the bony cancelli, so
that they form a finely spongy, dry and brittle structure, or more rarely
a dense and hard structure, resembling the skeleton of the external mass
of cancer.*
It remains that I should describe the Firm Medullart Cancers.
In all their general relations, — as to seat, shape, size, and connec-
tions,— these correspond with the softer kind. Like them, they may be
separate masses or infiltrated ; may have distinct investing capsules, or
may extend indefinitely in the proper substance of organs ; like them,
they are apt to affect a certain part or place rather than a single tissue :
or may be the seats of various degeneration or disease : their only pecu-
liarities are in their own structures.!
They are firm masses : not hard, like scirrhous cancers ; but firm,
elastic, tense, compact, and moderately tough ; they are as tough as
the more pliant examples of fibrous cartilage, and merge into exact
likeness to the less hard and more elastic scirrhous cancers. They are
not evidently fibrous, but tear or split as very firm coagulated albumen
might. Their cut or torn surfaces appear peculiarly smooth, compact,
shining, and sometimes translucent ; in some instances they are uni-
form and without plan ; in some, more regularly and minutely lobed,
* I have twice seen a formation of very firm fibrous substance, like the basis of the osteoid
cancers, in the cancellous tissue of bones that were surrounded with very 8of\ medullary
cancer. I have, also, seen a light brittle skeleton formed in the cancer external to a bone,
of which the cancellous tissue was converted into hard osteoid substance.
f Generally, I think, when they affect bones, the osseous tissue is apt to soften and
waste, rather than to. grow as it does in the soft medullary cancerous afiections. Certainly,
the flriD medullary cancers rarely have ^ternal skeletons.
568 MEDULLART CAKOEB — MICROSCOPIC BTRUOTURB.
or even imitating the appearance of any gland, such as the m^nmary
or parotid, in which they lie. Sometimes they present a strongly
marked grain, as if from fibres: but this results, I believe, from a
peculiar fasciculate and linear arrangement of elongated cells.
In color, the firm medullary cancers are hardly less yarious than the
softer kind. They may be pure white ; but more often are white,
tinted or streaked with pale pink, or yellow ; or they may be in nearly
every part buff-colored, or gray ; or these tints may be mingled and
mottled with blood-color, though not so deeply, or with such effusions of
blood, as are frequent in the softer tumors.
On pressure, especially after contact with water, they generally
yield a characteristic creamy or grayish fluid, which sometimes appears
strangely abundant, considering their firmness of texture. In a few
instances, however, this character is wanting ; the firmest tumors may
give only a thin turbid fluid.
Among the points of contrast, in the descriptions of medullary and
scirrhous cancers, is the wider range of variety exhibited by the former
in the original characters of its growth. For the diversities which I
have been describing are not to be referred to changes ensuing in differ-
ent stages of the same disease ; the firmer cancers do not graduaUy
become soft, nor the soft become firmer ; they are not to be connected
(as the chief varieties of scirrhous cancer may be) with the acute or
chronic progress of the disease, or with its different modes of growth,
or with the differences of age in which it occurs ; rather, the peculiar
features of each specimen, and of each chief group, appear to be original
and constant, — provided they are not affected by degeneration or disease.
Now, equal diversities exist in the microscopic structures of medullary
cancers. There are, indeed, certain characters to which nearly all are
conformed : the microscopic diagnosis is, therefore, seldom difficult, very
seldom doubtful ; yet many varieties of appearance need to be learnt,
both that the disease may be always recognized, and that we may, if
possible, hereafter accurately divide the inconveniently large group
into smaller ones. At present such a division is impracticable ; for we
can only sometimes trace a correspondence between a peculiarity of
microscopic structure, and one of general aspect, in the tumors ; but it
should be a chief object of future inquiries.
The varieties exist in both the corpuscles and the basis, stroma, or
intercellular substance of the cancer.
Among the corpuscles, the most frequent, and that which seems the
normal, form; is that of nucleated cells, which, in all essential charac-
ters, are like those of hard cancer (p. 526, Fig. 85). Examples of such
cells may be found in nearly every specimen, although, in certain in-
stances, other forms may predominate over them. There is, I beliere,
no mark by which they may be always distinguished from the cells of
hard cancers. They may be softer, less exactly defined, more easily
disintegrated by water, flatter than the cells of scirrhous cancer are,
HBSCLLART CAKCER — MICROSCOPIC BTBUCTDRE. * 569
bat there is in these things no important distinction. The only con-
stant difference is in the modes of compacting, and in the relations of
the cancer-materials to the natural structures in which they are placed.
Cells snch as, in scirrhous cancers, are closely placed, with a sparing,
firm, intermediate substance, or are tightly packed among the contracted
atmetnres of a mammary gland, arc in the medullary cancers more
loosely held together, in a more abundant, and much softer or liquid
intercellular substance.
The chief varieties of microscopic forms in medullary cancers may
be described as affecting, severally, the nuclei, the cells, and the inter-
cellnlar substance ; and it may be generally understood that each pecu-
liar form may occur in combination with a prodominant quantity of the
ordinary or typical cancer-structures, or may, in rarer instances, form
the greater part, if not the whole, of a cancerous roasM.
(a) Free nuclei, suspended in liquid or imbedded in a soft, nebulous,
or molecular basis-substance, may compose the whole of a very soft
medullary cancer. Appearances of cella may be seen among them, be-
cause of the adhesion of the basis-substance to them ; and appearances
of many-nucleated cells, when fragments of the basis are detached in
which several nuclei are imbedded. But certainly, in many instances,
formed cells are rare or absent.
The nuclei {Fig. 90) are like those of the typical cancer-cells (p. 526) ;
they are oval or round oval, having a long dia-
meter of from gg'oothto 3g'0i)tbof an inch, bright. Fig. 90.»
pellucid, perfectly defined, largely, and often
doubly Ducleolated.
It is in the structures thus formed that the
minute bloodvessels of cancer may bo best ex-
amined without injection ; for the soft material
in which they ramify may be washed away from
them, so as to leave them nearly alone, and fit
for examination as transparent objects.
(i) Free nuclei (Fig. 91), which may be considered as grown o
veloped, are often mixed, in various propor-
tions, with other cancer -structures. Some,
retaining the usual shape, are much larger
than the average: others, rarer and more
peculiar, are elongated, narrow, strip-like,
caudate, or pyriform. Some of these are
very small, slender, and apparently of simple
structure : others more nearly acquire the
size and other characters of cella. Their
contents are not so simple and pellucid as
• Fig. 90. Nuclei of soft mmluilarjr career, imbedded in s mol«ul»t basia-iubstanoe,
withoui cancer«ell«. Mngnitled »00 limeB.
t ^V- 81- Varlotw grown and developed nuclei of medullary cancer, as described in ihe
rde-
rig. «l.t
570 * HKDULLART CANCER — MICROSCOPIC STRnOTVBB.
those of ordinar; nuclei ; in the smaller they are darkly dotted or
granular, but no contuned particles appear larger than common nu-
cleoli. In others, larger, oval, pellucid corpuscles, like small nuclei,
are contained ; and these seem to be formed by the enlargement of the
nucleoli, which thus approach or attain the characters of nuclei, while
the nuclei that contain them are advanced to the condition of cells.
Most commonly, the cells, that thus seemed formed out of nuclei, am
singly nucleated ; but two or three nuclei are found in a few of large
size.
[c) In a few specimens of medullary cancer of the breast (p. 577),
and of the parotid, I hare found the chief constituent to be free or clut-
tered nuclei, of round or round oval shape {Fig. 92) from j^gth to
ig'ggth of an inch in diameter, well-defined, but not darkly, nebulous or
molecular rather than pellucid, and appearing to contain four, five,
or more shining granules, but no special or distinct nucleolus. They
Fig. 92 • Fig. 98.t
might have been taken for large corpuscles of inflammatory lymph, but
that neither water nor acetic acid affected them. They were imbedded
in a small quantity of molecular basis, and sometimes arranged b
groups, imitating the shapes of acini of glands. A few of smaller eite
but similar aspect appeared to be within cells.
(d) In a remarkable case, lately at St. Bartholomew's Hospital,!
woman, 67 years old, had two very large and several smaller tumors
connected with the skull, a tumor in the lower part of the neck, and
similar small growths in the lungs. They were all very soft, closfr
textured, white, or variously colored with extravasated blood, inclosing
large cavities filled with bloody fluid. Except that they yielded no
creamy fluid till after they were partially decomposed, one could not
hesitate to call them medullary cancers. But they were composed,
almost exclusively, of round, shaded nuclei, with three or four minute
shining particles, and in general aspect very like the dotted corpuBcla
of the spleen. Many of these were free ; but more, I think, were »^
ranged in regular clusters or groups of from five to twenty or more,
* Fig. 93. Dotted nuclei of medullary cancer, tieacrlbed in tlie text. Magnified JCO
j- Fig. 93. Clu9l«red nuclei of a medullpTy cancer, deacribed in the text. .M>|iiifit>l
MIDULLART OANCBB — HICB0800PIC STBUOTDKB. S71
composing roond, or oval, or cjlindrifonn bodies (Fig. 93). A few
similar noolei were inclosed singly in cells in the cancerous growths in
the lungs.
Such are the chief varieties in the nuclei of medullary cancers.
Scarcely less may be found in cells, mingled, let me repeat, in diverse
proportions, with cells or nuclei of typical form, and rarely surpassing
them in number.
(«) Besides those varieties in the shapes of cells, which were described
among the microscopic characters of hard cancers (p. 526), and which
are equally, or with yet more multiformity, found in these, we may
note the occasional great predominance of elongated caudate cells in
some examples of medullary cancers. I have hitherto observed this in
none bat some of the firmer specimens of the kind. Many such contain
only typical cancer-cells ; but in some the caudate and variously elon-
gated cells predominate, and, by their nearly parallel and fasciculate
arrangement, give a fibrous appearance to the section of the tumor.
The adjacent sketch (Fig. 94) is from the
cells of a very firm tumor that grew round '^'
the last phalanx of a great toe-t Its can-
cerous nature was proved not only by its
structure, but by its recurrence after am-
pntatioD, and by similar secondary disease
of the ingoioal glands. I found scarcely
any cells bat such as are drawn. Some ^ W <Tij*
were narrow, tongue-shaped, broad, and
rounded or truncated at one end, and at
the other elongated and tapering. Some were elongated at both ends;
some oat-shaped ; some very slender, with long awn-shaped, or cloven
processes. All these had large, oval, well-defined, clear nuclei, like
those of ordinary cancer-cells, and with distinct nucleoli. Their tex-
ture, also, appeared to resemble that of common cancer-cells ; they
differed only in shape, being, in this, most like the cells of recurring
fibrous tumors (p. 512).
(/} In two iDstances, I have found cancers which, by their general
diumcters and history, should be called firm medullary cancer, and
which were, in great part, composed of much smaller, narrower, and
proportionally more elongated cells than those last described. One of
these was a large deep-seated tumor behind the inner ankle and in the
sole of the foot, inclosing the posterior tibial and plantar vessels and
nerve, and the flexor tendons. In the other case, the primary tumor
inTolved the gnm and larger part of the front of the lower jaw ; and
nmilsr secondary disease was difiiised through part of the right lobe of
the thyroid gland, and, in small masses, in both lungs. All the tumors
* Fig. M. Candata and variously elongated cells of a firm niedullary cancer, described
in tb« text. MagniBed 450 times.
f MiB. Cba au^., 3S3 ; niidofSt.Banholoniaw'*,SeriMZUv, No.S4.
572 MEDULLARY CANCER — MICROSCOPIC STRUCTURE.
were very firm and elastic ; the fluid that they yielded was not creamy,
but viscid and yellowish. The tumor on the foot
^^' was gray, shining, minutely lobed, intersected
with opaque-white fibrous bands, and in its own
tissue appeared fibrous. That on the jaw was
grayish-white, suffused with pink, glistening, but
with no appearance of fibrous or other texture.
In all there were much molecular matter and
granular debris, canrfer-nuclei, and a few cells of
|N^y ^ /rT^ ordinary form ; but their essential structures
I ^J^ ^ were (as in Fig. 95) very small, narrow, and
elongated cells and nuclei. The cells were of
various shapes ; some sharply caudate, some swollen in the middle,
some abruptly truncated. They looked wrinkled and very pellucid.
They measured, generally, about yuuii^h ^^ ^^ mch. in length. Some
had elongated clear nuclei ; in others no nuclei appeared. Many free
nuclei had the same shapes as these cells, and of many corpuscles it
was hard to say whether they should be called cells or nuclei.
{g) Sometimes one meets with cells, in medullary cancers, in which
nuclei are not at first discernible. They are round, large, nebulous;
they contain many minute granules ; and, when water is added, it dif-
fuses their contents, and may display a round nucleus, smaller, and
more nebulous or granular than those of the typical cancer-cells.
(A) Cells containing many nuclei are regarded by some as frequent
in certain medullary cancers. I believe that such cells may occur, and
that occasionally endogenous cells may be found within those of larger
size and probably older growth : but I am more sure that cells contain-
ing cells, or containing more than three nuclei, are rare, at least in me-
dullary cancers, occurring in external parts. I must believe, from the
reports of others, that they are more frequent in cancers of internal
organs. t What have been described as brood-cells in medullary can-
cers, or as cells which, by the multiplication of their nuclei, were effect-
ing rapid increase of the cancer, were, I believe, in some instances, the
many-nucleated cells of myeloid tumors, and, in more instances, de-
tached masses or fragments of molecular basis-substance, in which nu-
clei were imbedded. I may add, that I have not found, in medullary
cancers, any structures similar to those of the laminated cysts or cap-
sules which occur in epithelial cancers.
Such are the chief varieties of the corpuscles of medullary cancer:
these, at least, are what I have found them presenting in their natural
state. Much might be said respecting the changes effected in them by
the fatty and other degenerations and diseases, and about the confusion
brought into the microscopic diagnosis by the granular masses, free
granular matter, and various ddbris hence derived. But for these I
* Fig. 90. Small elongated cells and nuclei, with nuclei of ordinary shape, from a firm
Aicdullary iinuor. as described above. Magnified r)00 times.
f Rokitansky delineates some (Ueber die Cysie, tigs. 9, 10, 11).
MBDULLART CANCER — MICROSCOPIC STRUCTURE. 578
must refer to the last lecture, and to the general account of degenera-
tions already given. "*" It remains that I should speak of the substance
with which the cells are associated, — the basis, intercellular substance,
or stroma.
I need not repeat what has been said (p. 531) respecting the " stroma,'*
so-called, of a cancerous infiltration, — that it is only the tissue of the
organ in which the cancer is seated. What I have now to describe is
the substance which is proper to the cancer, and in which the cancer-
corpuscles are suspended or imbedded.
(a) The cells and nuclei of medullary cancers may be suspended in
liquid alone ; and the two, like a collection of fluid rather than like a
tumor, may be infiltrated in tissues, or, more rarely, may be contained
in small cavities. This is not unfrequently the case in very rapid pro-
ductions of cancerous matter, especially in secondary deposits. The
liquid (cancer-serum, as it has been named) is turbid ; it dims trans-
mitted light, and has a finely molecular appearance. With the cancer-
corpuscles, and usually with granular matter, it makes the ^'cancer
juice;" the peculiar thick, creamy liquid, tinted with yellow, gray,
pink, or purple, and easily diffusible in water. The quantity of corpus-
cles in proportion to the liquid is various ; it may be so small, and the
corpuscles themselves may be so lowly developed, that the liquid may
appear the chief constituent of the cancer.
(6) The same kind of liquid which, in the cases just referred to, forms
the only material suspending the corpuscles, exists, also, in the solid
medullary cancers: it is the liquid of the "cancer juice.*' But in the
more solid growths it appears to be diffused through some solid tissue,
or in the interspaces of a kind of spongy texture. This, which may be
more properly called a stroma of medullary cancer, is in its simplest
form a nearly pellucid substance, having cither no trace of structure,
or only imbedded roundish or elongated nuclei ; but sometimes it ap-
pears fibrillated.
(c) Sometimes a framework, inclosing and supporting cancer-cells,
appears to be formed by elongated fibro-cells arranged in series of com-
municating lines. But, more commonly, a framework is constructed of
delicate pellucid or nucleated membrane, with filamentous tissue. In
the last case one obtains from a medullary cancer, after expressing as
much as possible of its *' juice,** a kind of sponge, flocculent and
shreddy, constructed of membrane and filamentous tissue, with blood-
vessels, and Rtill-adhering cancer-particles. One thus sees that, even
in the minuter parts, the substance of the growth is intersected with such
partitions as are visible with the naked eye, separating it^ hirger lobes.
(d) Lastly, when medullary cancer is formed in bone or periosteum,
these tissues may, as I have said, grow excessively, and make for it a
fibrous or osseous skeleton (p. 566). Or, in other cases, new fibrous or
* Or, with more advantage, to Lebert's admirable account of the chani^es of the cancer-
cellfl, io his ** Trait^ pratique/* p. '23.
574 MBDULLAKT OAHOB — MI0B08C0PI0 BTBUOTITBB.
osseOQB tissne may be formed in the cancer, and may be as a stroma fat
the cancer-cellB. Hednllary cancerB thns composed are the ofaief ez-
amplea of traDBition-forms to the Bcirrhona eaDoere, on the ooe hand;
and, on the other, to the osteoid oancere, in which the cancer-cells ve
wholly or nearly superseded by an imperfect oseific prodncticm.
Bokitansky some time ago published an essay* on the derelopmeBt
of the stroma or skeleton of cancers, an abstract of which, with ooiuet
of some of his illnstrationa, may find here an appropriate place. It
relates, almost entirely, to
^'s- *"t that kind of stroma, in
medullary eanoera, whioh
ia described abore (e, p.
578).
In certain examples <€
sach a stroma or skeleton,
two interlacing networki^
or meshed straotares, may
be Been (Figs. 96, 97). One
of these (i) connsta of slen-
der bands, beams, or tabes
(Fig. 96, e) of a hyalisB
BQbstance, which oontaias
oblong naolei, and may be
in part fibrillated or trans-
formed into filamentoiu
tissue. The other and
younger structure (a) i>
composed of larger opaque
bands or beams, which an
made up of nncleated oelli,
with elementary granules,
and Tariously perforated.
These form a network in-
terlacing with that fomwd
by the hyaline stmcturea
Moreover, with Iheu
opaque beams, formed of
the same structures, asd
projecting from them, ot
from the fay aline stmutures,
there are hollow flask-
shaped or villous proeesaes
* Ueber di« Enlwickelung dar Ereb>«erftMe, 1852, rrom Ihe Sitmngaberichte d« Kiifc
t Figs. 96 and 97. Developmroi oTGancer^tioma, dMcribed in ih« tesL Hagiufled W
liiDM. From Rokitiiukr.
MBDULLART CANCER — MICROSCOPIC STRUCTURE. 575
or outgrowths (Fig. 97). Many of these pass through the apertures or
meshes in the networks, projecting through them with free ends ; and
the apertures with which many of them are perforated, enlarging by
absorptioib, give them the appearance of netted hollow bands or cords.
Some of these same processes, also, appear pellucid, hyaline, and nucle-
ated at their bases or pedicles of attachment, or through more or less
of their length.
These several conditions of the stroma indicate, Rokitansky says,
that it is constructed on that plan of *' dendritic vegetation," of which
the type and best example is in the villous cancers. The growth of
the stroma takes place, at first, in the form of hollow, flask-shaped, bud-
ding and branching processes or excrescences, which are composed of
hyaline membrane, and filled with nucleated cells and granules. These
processes constantly increase, throwing out fresh offshoots of the same
shape as themselves first had (comparably with the increase of the exo-
genous villi of the cystic chorion described at p. 378). At the same time
the cells, or part of the cells, within the processes, unite or fuse their
cell-walls, while their nuclei remain and are elongated. Thus the tex-
ture of the growing stroma becomes hyaline, nucleated, or at last fila-
mentous and tubular ; and, as apertures are formed in it by partial
absorption of its textures, it becomes also meshed and reticulate or
sponge-like. Fresh dendritic vegetations arising, on the same plan,
from the network thus formed, pass with interlacements through its
meshes ; and, by repetition of the changes just described, increase the
stroma and the complexity of its construction.
The production of cancerous elements is commensurate with the
growth of the stroma, and they fill all the interstices, as well as, in
some cases, the tubules of the networks. "*"
* Rokitansky holds that the same method of construction is to be traced in the formation
of the layers of folse membrane, which are found with reticulate or areolar surfaces, or,
later, with interlacing laminee of fibres, on the pleura and other serous membranes. He
illustrates it, also, by the reticulate deposits on the interior of arteries; and, lastly, by the ex-
amples of cavernous or erectile tumors, t. «., not of such as he admits to be formed by dila-
tation of bloodvessels, but of such as are entirely new-formed structures. I have supposed
these (see p. 504) to be new growths, in which the bloodvessels greatly enlarging produce
the character of an erectile tissue. Rokitansky says that processes spring from the bands
and the cords of the cavernous tissue of such tumors, which processes end with flask-shaped
swellings, and are either opaque, and formed of nucleated cells, or are formed of nucleated
hyaline tissue, or of long fibro-cells, or of fibro-cellular tissue. From these likenesses he
deduces for the cavernous tumors the same plan of development as for the stroma of cancer.
He believes, moreover, that the blood which some of them contain is formed in them : say-
ing that, in small, lately-formed erectile tumors, no anastomosis between their blood-spaces
and the bloodvessels in the parts around them can be found.
Lastly, he says (and the statements may be added to what is mentioned at p. 508), the
affinity of the cavernous blood-tumor with cancer is more than a formal one. They not
unfreqoently exist together in the same organ, e. g.^ in the liver; and the stroma of the can-
cer may be exactly like the mesh work of the vascular tumor. Cavernous tumors, also, may
be found in large numbers at once in the most different organs and tissues : for example (as
«
576 MEDULLARY CANCER OF THE TESTICLE.
The foregoing descriptions, though illustrated by only a few exam-
ples, might suflBce, I believe, for the medullary cancers of nearly all
parts. Yet it may be useful, if, after the example of the other lectures,
I describe some of the peculiarities which this form of cancer presents
in certain organs, — making a selection on the same grounds as in the
last lecture (p. 533).
In the Testicle, the medullary cancer is, usually, of the softer kind:
the firmer kind is not uncommon, but examples of the scirrhous, or any
other form of cancer, except the medullary, are of exceeding rarity.
The medullary cancer commonly appears as a regular oval, or pyri-
frfrm mass, which the toughness of the inclosing fibrous coat of the tes-
ticle permits to grow to a great size without protrusion. As the fibrous
texture is distended by the growth, so it commonly also increases in
thickness. The surfaces of the tunica vaginalis are generally partially
adherent ; and what remains of the cavity, usually at its upper part,
is filled with serous or blood-tinged fluid. Part, or the whole, of the
glandular tissue of the testicle may, I think, be always found outspread
on the surface of the tumor : the epididymis, often the seat of similar
disease, is generally flattened and expanded. Separate medullary can-
cers may lie near ; especially in the loose areolar tissue of the spermatic
cord : or the growth may perforate the tunica albuginea, and extend
exuberantly about the testicle in ihe sac of the tunica vaginalis, or in
the loose tissue of the scrotum : or, without communication, part of the
cancer may be within, and part around, the tunica albuginea.*
The general characters of the cancer-structure in the testicle are
usually conformed to the type already described, yet these points may
be considered worthy of note. (1.) Sometimes the lobes of the can-
cerous mass are severally so invested with connective tissue that they
may have the appearance of cysts filled with endogenous cancerous
growths.f (2.) Portions, or whole lobes, of the tumor, degenerate and
in a case related by him), in the whole peritoneum, the costal pleura, the subcutaneous tis-
sue, one of the psoas muscles, the choroid plexuses, and the fat at the base of the heart.
Many of the later writers on the structure of cancer consider, that both the cancer-cells
and the peculiar trabecular stroma, in the spaces between which the cancer-cells are Indited,
are developed from the original connective tissue of the part in which the cancer is situated.
This development being due to the proliferation of the corpuscles of the connective tissue,
which, on the one hand, may produce the cancer cells, on the other, may develop in siich
a way as to form the peculiar, villous, papillary, or ilenjlritic vegetations above described.
When once formed, these trabeculoE* may increase in size through the activity of the cells
contained in their interior. In this manner a structure and general plan of arrangement
may be produced not unlike that which has already been described in cylindroma, p. 41^.
* Mr. Prescott Hewett showed me a specimen in which a healthy testicle was surnnmded
by medullary cancer. Exam|)les of similar cancers in the spermatic cord, the testicles being
healthy, are in the College Museum, Nos. 2462-3 : some affecting the undest^ended testicles
are related by Mr. Arnott (Med.-Chir. Trans., xxx, p. 9), and by Dr. Fayrer in Edin. Month.
Med. Jal, March, 1803.
t Mus. Coll. Surg., No. 23%.
MEDULLARY CANCER OF THE BREAST. 577
"withered into a yellow snbstance, like tuberculous or " scrofulous"
matter, are usually seen ; especially near the central parts of the can-
cer. (3.) Large cavities full of blood may exist, and add to the diffi-
culty of the diagnosis from hsematocele. (4.) The conjunction of me-
dullary cancer with cartilage is more frequent in the testicle than in
any other part (see p. 459). (5.) The disease very rarely affects both
testicles, either at once or in succession.
The medullary cancer of the Eye so rarely deviates from the general
characters of the disease, and, since Mr. Wardrop's first account of it,
has been described, in all works on Ophthalmic Surgery, so much more
fully than would here be reasonable, that I shall advert to only two
points which it illustrates. (1.) It is especially apt to present, either
in parts or throughout, the melanotic form ; a fact which we can hardly
dissociate from that of its growth near a seat of natural black pigment,
and which illustrates the tendency, even of cancers, to conform them-
selves, in some degree, to the structures of adjacent healthy parts. (2.)
It shows a remarkable disregard of tissue in its election (if it may be so
called) of a seat of growth. I fully agree with M. Lebert in his denial
of the opinion that either the retina, or any other tissue of the eyeball,
is in all or even in a large majority of cases the place of origin of the
cancer. Rather, we have, here, a striking instance of what may be
called the allocation of cancers : of their growth being determined to
certain places rather than to certain tissues. Any of the tissues within
or about the globe of the eye, or any two or more of them at a time,
may be the primary seat of thd cancer ; and, probably, each of them is
more liable to be so than any similar tissue elsewhere is : the locality,
therefore, which they all occupy, may be assumed as that to which the
cancerous growth is directed, rather than any of the tissues themselves.
And so it appears to be, when, after extirpation, the cancer returns, as
if with preference, in the same locality, although the whole of the first
growth, and of the tissues which it occupied, are removed.
The Breast is among the parts which are most rarely the seats of
medullary cancer. I cannot tell exactly the proportion which the cases
of medullary bear to those of scirrhous cancer ; but I think it is not
greater than five to ninety-five in this country ; an infrequency which
seems the more remarkable by its contrast with the occurrence of the
disease abroad. In France, according to M. Lebert,* about one-fifth
of the cancers of the breast are "soft and encephaloid.*' In America,
Dr. J. B. S. Jackson has assured me that the proportion is not less
than one-fifth ; and I gather, from the records of German writers, that
it is with them about the same.
I have never seen, in the recent state, a medullary cancer of the
* Des Maladies Cancereuses, p. 326.
678 MEDULLARY CANCER OF THE BREAST.
breast which had a brain-like or any other usual appearance :* but I
have observed four cases of what must be regarded as medullary cancer,
though widely deviating from the usual characters, and not resembled
by any of the samekind except some of those occurring in the brain.
They may be worth description, because they are with difficulty dis-
tinguished from hard cancers, on the one hand, and from mammary
glandular or cystic tumors, on the other. If a general description may
be drawn from these few cases, it may be to the following effect.
The tumors are separable masses, closely connected with the sur-
rounding mammary gland or fat, but not incorporated with them, and
having, in some instances, distinct thin capsules, — a character at once
distinguishing them from all the scirrhous cancers of the breast that I
have yet seen. They are, generally, seated on or near the surface of
the gland, "floating,*' as mammary glandular tumors often do. The
skin over them is upraised, thin, and tense ; not depressed, or morbidly
adherent, or itself cancerous ; but when ulceration is at hand, becoming
livid, then ulcerating sparingly, and then everted with the protruding
and outgrowing tumor. The tumors are oval, flattened, rounded, or
nodular ; firm, sometimes very firm, but not hard or very heavy like
scirrhous cancers, and at or about their centres they feel like cysts
tensely filled with fluid. They may grow quickly, and to much larger
size than scirrhous cancers ; are not remarkably painful ; and appear
prone to be associated with the formation of large serous cysts. Their
general history is that of ordinary medullary cancers.
With these characters alone, the diagnosis of such medullary cancers
of the breast is very diflScult ; all these equally belong to mammary
glandular tumors or proliferous mammary cysts. But the same disease
may exist in the axillary lymphatic glands, forming quickly-growing
masses, apt to be much larger than those in scirrhous cancer. And, if
ulceration ensue in the tumor, it becomes exuberant, with lobed and
coarsely-granulated firm growths, discharging offensive ichor, and som^
times profusely bleeding.
When such tumors are removed, they are found, as already stated,
separable from the mammary gland ; it is pressed away by them, bat
is itself healthy. The section of the tumor is minutely lobed, with
lobes or "granulations*' closely grouped, like those of a mammary
glandular tumor. Their texture is close, more or less firm, easily
crushed, shining on the cut surface. In color, they are grayish, varied
with dots and irregular lines of yellow (which do not follow the course
of the gland-ducts), or, in parts, suffused with livid or deeper purple
tints. Parts of them, or even whole lobes, may be soft, shreddy, pale
yellow, like tuberculous infiltration ; and these seem to be portions that
* I do not 8o consider two specimens in the Museum of St. Bartholomew's, Series xxx^«
28, 29, removed from the front of the chest after amputation of the breasts on account of
extreme hypertrophy.
MEDULLARY CANCER OF THE SUBCUTANEOUS TISSUE. 679
are degenerate and withered, like the tubercnloid materials in other
medullary cancers. They yield, not a creamy fluid, but a turbid gray-
ish, or viscid yellowish one. In some instances large cysts lie in or
upon them, filled with serous, or blood-stained, or darker fluid.
In microscopic examination traces of a glandular acinous plan may
be again observed : the corpuscles of the tumor being, at least in parts,
grouped in round or oval forms, though the groups are not inclosed in
membrane. The corpuscles may be well-formed cancer-cells and nuclei
imbedded in molecular substance. But I have also found in them, with
these or alone, abundant nuclei (some free and some in cells), such as
are described at page 570, Fig. 92. It was, chiefly, such nuclei as
these, which, being clustered, gave the minute appearance of glandular
construction: and in some parts, these alone, clustered and close
packed, seemed to make up nearly the whole substance of the tumor.
In the Subcutaneous Tissue, or deeper areolar layer of the skin,
the medullary cancers, while generally conformed to the type, exhibit
these peculiarities :
(1) They are apt to assume the melanotic state ; a fact allied to that
already mentioned of the cancers of the eyeball.
(2) While, in nearly all other external parts, the medullary cancers
appear as single growths, they are here very often multiple. Such
numerous cancers may grow after one affecting some distant organ ; or
may be first formed below the cutis. In the latter case, many may
appear coincidently ; or, when in succession, none seem to be conse-
quences of the growth of their predecessors ; they all have the charac-
ters of primary cancers, of " cancers d*embl^e." In some cases all the
tumors appear in a single region of the body. In an old man, lately
under Mr. Lawrence's care, two medullary cancers were removed from
the scalp, and four remained in it. In a case, which I shall presently
detail, a large number were seated on one arm and shoulder, but scarcely
any appeared elsewhere. In some cases, on the other hand, they ap-
pear at about the same time in many and distant parts ; and in some,
though limited at first to a single region, they grow successively in
other parts more and more widely distant. Such was the event in a
remarkable case by Dr. Walshe.*
In this aptness to be the seat of many medullary tumors, the subcu-
taneous tissue agrees most nearly with the serous membranes and the
liver and other glands. The separable tumors are generally isolable,
oval, discoid, or lens-shaped : very rarely, I believe, they are peduncu-
lated : they do not commonly grow to a great size, or tend to ulcera-
tion or protrusion, unless after injury. But there seems no limit to
* Medical Times and Gazette, Aug 21 and 28, 185*2. In his treatise on Cancer, Dr.
Walshe gives a fnll analysis of all the cases previously published. See also the singular
case recorded by Mr. Ancell (Med. Chir. Trans., xxv, p. 227).
580 MEDULLARY CANCER OF THE LYMPHATIC GLANDS.
their number ; it is as if the force of the disease which, in other in-
stances, is spent in a single enormous growth, were here distributed
among many.
(3) It is chiefly among these examples of multiple medullary cancers
that the occasional disappearance of a cancer, as if by absorption, may
be observed. The old man referred to, as under the care of Mr. Law-
rence, was admitted because one of the tumors in his scalp was largely
and foully ulcerated. The removal of it was deferred, on account of
the other tumors, and especially on account of one behind the ear ; but
in the course of about a month this almost wholly disappeared; the.
largest of those remaining was now removed ; and during the healing
of the wound the rest nearly disappeared, becoming gradually smaller
and firmer. So, in the case of multiple tumors of the arm, before the
patient died, the whole of the smaller tumors were completely removed
during the sloughing and suppuration of the larger.
The Lymphatic Glands, so rarely the seat of primary scirrhous
cancer, are often primarily affected with medullary cancer. They are,
indeed, less frequently so affected than they seem to be ; for, in some
instances, when the disease seems primary in them, it is only because
of its predominance over that in the organ with which they are con-
nected. But, in more instances than these the glands are first, and for
a time, exclusively affected. The most frequent seats of such primary
disease are the cervical, inguinal, lumbar, axillary, and mediastinal
glands : in a few very rare instances nearly the whole lymphatic system
has quickly become cancerous.
The primary cancer of the lymphatic glands usually affects, from the
first, more than one gland; often, it extends through a whole group,'
and so many tumors form in a cluster, that one may doubt whether all
of them are in glands. They may present any of the various forms of
medullary cancer ; and these peculiarities may be noticed in their
course : (1) They are rarely well marked in the first instance ; thej
appear like merely enlarged glands ; their constant and accelerating
increase may alone suggest the suspicion of the nature of the disease.
(2) Cyst-formation is frequent in connection with them. Especially, I
think, in the neck, one may find serous cysts, in elderly persons, rest-
ing on clusters of cancerous glands, and the cysts may be often eva-
cuated, and will fill again, while the main disease makes insidious
progress deep in the neck. (3) Partial suppurations may occur in the
cancerous glands, rendering the diagnosis for a time still more difficult.
(4) It is especially among the cases of cancerous lymphatics that we
may find those occurrences of deep connection, and of inclosing of large
nerves and bloodvessels, to which I have referred (p. 563). (5) Can-
cerous lymphatic glands often give a fallacious support to the belief
that innocent tumors are apt to become cancerous; for the glands some-
times enlarge before the cancerous disease is established in them ; and
MEDULLARY CANCER — PATHOLOGY. 581
since, in their simple enlargement, they are like simple tumors, there
is an appearance of transmutation, when in such a state they become
the seats of cancer.
In the Rectum, and in other parts of the digestive canal, I have
already said that growths of medullary cancer may coexist with scir-
rhous cancer. Whether in this combination or alone, the former dis-
ease may appear in at least three distinguishable forms. (1) It consists
sometimes in diffuse infiltration of creamy, white, or grayish cancerous
substance in the submucous tissue, the mucous membrane being, for a
time, healthy, but raised into the canal with low unequal elevations.
(2) Much more commonly, larger and more tuberous circumscribed
masses grow in the submucous tissue, projecting and soon involving the
mucous membrane, then exuberant through ulcerated apertures in it
and often bleeding. (8) With nearly equal frequency the disease has
its primary seat in the mucous membrane. Here it forms broad, cir-
cular, or annular growths, of a soft, spongy, and shreddy substance.
They are but little raised above the level of the mucous membrane, unless
it be at their margins, which are usually elevated and overhanging, and
when ulcerated, sinuous and everted. They are very vascular, justi-
fying Rokitansky's expression, that the bloodvessels of the affected part
of the membrane have assumed the characters of those of an erectile
tissue. They might produce little stricture of the canal, if it were not
that they are, I think frequently, associated with thickening and con-
traction of the tissue external to them.
It hardly needs to be added that in whichever part of the intestine
the disease commences, it extends to the rest, and from them to the
surrounding tissues ; exemplifying here as everywhere the coincident
processes of destruction and of more abundant formation.*
LECTURE XXXI.
MEDULLARY CANCER.
PART II. — PATHOLOGY.
The general history of medullary cancers presents the best marked
type of malignant growths. Among all tumors, they appear, in a gene-
ral view, the most independent of seat and of locality ; the most rapid
* When I have omitted all description of the medullary cancers of the uterus, kings,
brain, and many other organs in which tliey frequently occur, it will not, I hope, be forgotten,
that my purpose is only to illustrate the general pathology of the disease by the best ex-
amples which I have been able to study. To have entered further on the special pathology
of cancer in each organ would have been beyond my purpose, and quite superfluous while
*iie great works of Walshe and Lebert can be consulted.
682
MEDULLARY CANCER.
in growth ; the most reckless in the inyasion of diverse tissues ; the
most abundant in multiplication : they have the most evident constitu-
tional diathesis ; they are the most speedily fatal. All these facts will
be illustrated by comparison of the following sketch with the correspond-
ing histories of the other forms of cancer.
(a) Among the conditions favoring the production of medullary can-
cer, the peculiarities of the female sex, though not without influence,
appear far less powerful than they appear in the history of scirrhous
cancers. The peculiar liability of the uterus so much surpasses that
of any of the male organs of generation, that women are certainly, on the
whole, more liable than men are to this form of cancer. But when
the medullary cancers of the generative organs ot both sexes are left
out, the majority of the remaining cases arc found among males.
(6) The medullary cancer is prone to occur at an earlier age than any
other form ; it is, indeed, almost the only cancerous disease that we
meet with before puberty. The three localities in which, according to
M. Lebert,* cancer occurs at the lowest mean age are (in the order of
their liability), the eye, the testicle, and the osseous system. To these,
while confirming his observation, I would add, the intermuscular spaces,
and other soft parts of the trunk and limbs. The mean age of the
occurrence of cancer in these parts is under 40 ; in all other parts it is
above 40, and in most of them above 50. Now, the four localities named
above are those in which the medullary and melanotic cancers almost
alone occur as primary affections.
From a tablef of 154 primary medullary cancers of the bones, soft
parts of the trunk and limbs, the eye and orbit, the testicle, breast, and
various other external parts, I find that the ages at which they occurred
were as follows :
Breast.
8oa
parts of
limbs
and
trunic.
Lym-
phatic
glands
and
other
parts.
Bones.
Eye and
orbit.
Testicle.
1V>taL
Before 10 years of age, . .
Between 10 and 20, ... .
** 20 " 30, . . .
" 30 " 40, . . .
" 40 " 60, . . . .
*' 60 " 60, . . .
Above 60
2
2
3
2
6
3
3
6
2
1
3
2
2
3
4
12
11
6
11
4
6
16
1
4
2
1
6
3
4
2
12
17
8
3
25
21
33
32 1
;«)
20
10
7
23
10
64
31
46
171
The striking contrast between this table and that of the 158 cases
of scirrhous cancer (p. 542) needs little comment. Of the scirrhous
* Traite Pratique, p. 140. See also one of the tables in Med.-Chir. Trans., vol. xlv,p. 393.
t The table is constructed from nearly equal numbers of M. Lebert's cases and my own;
and it may be made worthy of remark, that in the case of every part the average age is
higher in his cases than in mine.
HERBDITART INFLUENCE. 583
cancers, not one occurred before the age of 20 ; of the medullary can-
cers, more than a fourth began before that age : of the former, nearly
half commenced their growth between 40 and 50 years of age ; of the
latter, little more than a sixth : of the former, nearly three-fourths
commenced after 40 ; of the latter, little more than one- third did so.
The following table, also, may be compared with that at p. 543. It
shows, by similar calculations, the relative frequencies of medullary can-
cers in external parts, in proportion to the number of persons living
at each of the successive decennial periods of life. The greatest fre-
quency is between 40 and 50, and reckoning this as 100, the following
nambers may represent the frequencies of the beginning of medullary
cancers at other decennial periods :
0 to 10 years, 31
10 •* 20 ** 38
20 " 30 ** 59
30 ** 40 " 79
40 " 60 " 100
50 « 60 " 99
Above 60 " 44
The chief points which this table may illustrate are (1), that the
maximum of frequency, in proportion to the number of persons living
at the several ages, occurs between 40 and 50, as well for the medul-
lary as for the scirrhous cancers of external parts ; but (2) that there
is a gradual ascent to this maximum from the earliest period of life, and
then a more gradual descent from it.
I believe, however, that if we could reckon the frequencies of medul-
lary cancers of internal organs, we should find no such diminution after
the age of 50. Rather, it would appear that (in consequence, chiefly,
of the frequency of cancer of the stomach, rectum, and bladder in ad-
vanced life) the frequency of medullary cancers, in proportion to the
number of persons living, continues to increase up to the latest age.
There are, I believe, no tables in which the medullary are separated
from other cancers of internal organs ; but from those of the cancers of
the nterus and stomach given by Lebert, and of the lungs by Walshe
(of which, doubtless, the majority were medullary cancers), the pro-
portionate frequencies at successive periods appear to be as follows.
(For comparison's sake, the proportion between 40 and 50 years is still
counted as 100.)
0 to 10 years, 0
10 ** 20 ** (cancers of the lungs alone), .... 3
20 " 30 " 15.7
30 « 40 »» 51
40 • 50 " 100
60 ** 60 " 204
60 " 70 •• 236
70 ** 80 •* (cancers of the stomach almost alone), . 250
There are no data from which we could exactly reckon the relative
584 MEDULLARY CANCER.
frequencies of medullary cancer in each part of the body, but there can,
I think, be little doubt that it is a disease which, on the whole, becomes
constantly more frequent, in proportion to the number of persons living
at each successive period of life, from the very earliest to the latest age.
({?) The influence of hereditary tendency is, probably, about the same
in medullary as in scirrhous cancer. Among thirty-two patients, five
were aware of cancer having occurred in other members of their fami-
lies, and of these five, four reported that two members of their re-
spective families had died cancerous.
(d) Among fifty-seven patients with medullary cancer of external
parts, seventeen gave a clear history of previous injury or disease of
the part affected ; in seven the history was doubtful.
Certainly it would be impossible to prove, in many of these cases,
that the cancer was, in any sense, consequent on the injury after which
it formed ; and yet, while we find that a third of the patients with me-
dullary cancers ascribe them to injury or previous disease, while less
than a fifth of those with simple tumors, or with hard cancers, refer
them to such cause (p. 545), we cannot fairly doubt that these local
accidents have influence in determining the place and time in which the
medullary cancerous disease shall manifest itself.
The influence of injury is very clearly shown in certain cases, in
which there is no appreciable interval between its immediate ordinary
consequences and the growth of a medullary cancer in the injured part.
For example, a healthy boy was accidentally wounded in the eye. It
had been perfectly sound to this time ; but, within a few days after the
injury, a medullary tumor grew from the eyeball. It was removed
three weeks later ; but it quickly recurred and destroyed life.
A boy fell and struck his knee. It had been perfectly healthy; but
the inflammatory swelling (as it was supposed) that followed the fall
did not subside; rather, it constantly increased; and in a few weeks it
became probable that a large medullary tumor was growing around the
lower end of the femur. Amputation proved this to be the case.
Again, a sturdy man, at his work, slipped and strained, or perhaps
broke, his fibula. Three days afterwards he had increased pain in the
injured part, and at the end of the week swelling, which, though care-
fully treated, constantly increased. Eight weeks after the injury the
swelling was found to be a large medullary growth around and within
the shaft of the fibula ; and the limb was amputated.
We must, I suppose, assume the previous existence of a cancerous
diathesis in the persons in whom these rare consequences of accidental
violence ensued ; nevertheless, their cases prove, as I have said, the
influence of local injury in determining the time and place in which the
cancer will be manifested; and they may make us believe that, in many
cases, in which a clear interval elapses between the injury and the ap-
pearance of the cancer, the effect of the violence, though less immedi-
ate, is certain.
INFLUBNOB OF GENERAL HEALTH. 585
{e) Although I know of no numerical evidence to support it, yet I
think the general impression must be true that medullary cancer is
peculiarly liable to occur in those who have many of the features of the
fair strumous constitution : in persons of fine complexion, light hair and
eyes, pale blood, quick pulse, and of generally delicate or feeble health.
Scirrhous cancer appears most frequent in those who have the opposite
characters of temperament. A difference also exists in relation to the
general health of those in whom the two forms of the disease are seve-
rally observed. I mentioned (p. 545, note) that 95 per cent, of the
subjects of hard cancer appear to have good general health at and soon
after its first appearance : the proportion of those in the like condition
with medullary cancer is about 89 per cent. ; the remainder have pre-
sented from the very beginning a loss of weight and of muscular power,
accelerated action of the heart, quick breathing, paleness, and general
defect of health.
In the growth of medullary cancer we may chiefly observe these
three things, — (1) their multiplicity in certain cases ; (2) their gene-
rally rapid rate of increase ; (3) the occasional complete suspension of
growth.
I have referred to their multiplicity in the subcutaneous tissue, but
again notice it, to mention the observation of Rokitansky,* that medul-
lary cancers are sometimes developed in great number in the course
and among the phenomena of a very acute typhoid fever.
I do not know what their greatest rate of increase may be ; but it has
in several cases exceeded a pound per month, and, except in the in-
stances of some of the cartilaginous tumors (p. 443), it is, I believe,
unequalled by any other morbid growth. In general, the more rapid
the growth the less is the firmness, and the less perfect the development
of nuclei and cells, in the medullary tumor. Their rapid increase
commonly indicates, not a special capacity of growth or multiplication
of cells in the tumor already formed, but an intense diathesis, an ample
provision of appropriate materials in the blood. The growth is by
simple increase : the materials once formed do not normally change
their characters ; there are no stages of crudity or maturity ; the dis-
ease is, in its usual and normal course, from first to last the same.
But while these things justify the expression that the medullary is,
on the whole, the most acute form of cancer, yet there is, I believe,
none in which arrest or complete suspension of progress is so apt to
occur. These cases have occurred within my own observation. A
man, 88 years old, had a slight enlargement of one testicle for fifteen
years, and its rate of increase was often inappreciable. At the end of
this time rapid growth ensued. On removal, well-marked medullary
and melanotic cancer was found, and was the only apparent source of
* Pathologiscbe Anatomie, i, 373.
38
586 MEDULLARY GANCBR.
I
the enlargement. He died soon after the operation with recurrence of
the disease.
A man, 42 years old, had a large increasing medullary tumor of the
ilium. He had also a tumor in the upper arm, which had grown slowly
for seven years, and had been stationary for three years. When he
died, the tumor in the arm had as well-marked characters of medullary
cancer as that of the ilium, or of any other of the several parts in which
similar disease was found.*
A man, 85 years old, had numerous medullary tumors* in his right
upper arm, shoulder, and axilla, all of which had commenced their
growth within three months, and were very quickly increasing. One,
which appeared to be in every other respect of the same kind, had
been stationary for twelve years in the groin, and another nearly as
long in the neck.
Sir Astley Cooper removed a gentleman's testicle for what was be-
lieved to be medullary cancer. He remained well for twelve years,
and then died with certain medullary cancer in the pelvis.
Dr. Baly had a patient who had observed for several years a tumor
connected with two of his ribs. It had scarcely enlarged, till shortly
before his death ; then it quickly increased, and, at the same time, nu-
merous medullary cancers appeared about it and in more distant part8.t
Cases such as these occur, so far as I know, in no cancers but those
of the medullary and melanotic kinds. They seem to be quite inex-
plicable ; and as yet no facts have been observed which would show a
peculiarity of structure in the arrested cancers corresponding with the
strangeness of their life.
As the medullary cancers grow, the parts about them generally yield,
and some among them grow at once in strength and in extent, and for
a time retard both the increase and the protrusion of the tumor. Be-
cause the skin over a medullary cancer is not often infiltrated (as that
over a hard cancer usually is), we do not often see the kinds of ulcer
described in the last lecture (p. 547). Neither is there, in medullary
cancers generally, any remarkable proneness to ulceration. The usual
course is, that, as the tumor grows, the skin and other parts over it
become thinner and more tense ; then, as the growth of the tumor is
more rapid than theirs, they inflame and ulcerate, and a hole is formed
over the most prominent part of the tumor. There is nothing specific
or characteristic in this ulceration ; it is only such as may ensue over
any quickly-growing tumor ; but the continued rapid increase of the
cancer makes it protrude and grow exuberantly ; it throws out fungus,
as the expression is. The exuberant growth, exposed to the injuries
* Museum of Si. Bartholomew's, Series i, Nos. 235 to 240. Case related by Mr. Stanley
in Med.-Chir. Trans., xxviii, p. 317.
f The tumor on the ribs is in the Museum of St. Bartholomew's. It appears an ordinary
medullary cancer, with a hard bony skeleton.
MODE OF GROWTH. 587
of the external world, inflames, and hence is prone to softening, bleed-
ing, ulcerating, and sloughing.* These may keep down its mass ; yet
it may grow to a vast size, having only its surface ulcerated ; lower
down, it usually adheres to the borders of the apertures in the skin, and
overhangs and everts them. This is usually the case with the huge
outgrowths of medullary cancer that have protruded from the eyeball,
after penetrating through ulcers of the overstretched cornea or sclerotica.
And similar exuberant growths are often seen when medullary cancers
have penetrated the walls of various cavities or canals : thus, e, g.y they
grow along the canals of veins when they have entered them by, it may
be, a single small orifice.
In the cases of diffuse infiltration of an exposed superficial tissue
{e. g.j of the mucous membrane of the stomach or rectum), the cancer
usually ulcerates widely with the tissue it affects, and herein imitates
more nearly the characters of the ulceration in scirrhous and epithelial
cancers.
Through the constantly deepening cachexia, with which the increase
in the medullary cancers is usually commensurate, and which is aug-
mented by the various influences of the local disease, the usual course
of the medullary cancer is uniformly towards death; and rapidly
thither, even when the growth does not involve parts necessary to life.
And yet, as Rokitansky has observed,t there is no form of cancer in
which spontaneous natural processes of healing so often occur. Doubt-
less nearly all the reputed cases of the cure of cancer have been errone-
ously so regarded; yet instances maybe easily gathered of at least'
temporary cure ; and these arc important in relation to the general
pathology of cancer, since they afford the best examples of the effects
of its degenerations and diseases. t
The degenerations of medullary cancer are chiefly three : withering,
fatty, and calcareous degeneration. Its chief diseases are equal in
number, — ^hemorrhage or apoplexy, suppuration, and sloughing.
A medullary cancer may gradually decrease, becoming harder, as if
by shrivelling and condensing, and at length may completely disappear.
I have mentioned such cases at p. 580 ; and I have seen the same
happen after partial removal of cancers.
A firm medullary tumor was seated deep in the substance of a young
woman's parotid gland. Its removal with the knife could not be safely
* In Series zxzv, No. 60, in the Museum of St. Bartholomew's, is a large medullary tiimor
wliieh had grown in the subcutaneous tissue of the back, and, aAer the skin over it had ul-
cerated, was in one mass squeezed out through the opening, while the patient was endeavor-
ing ID raise herself in bed.
f Loe. cit, p. 375.
{ A probable instance is related by Pirc^off (Rlinische Chirurgie, i, p. 45). It was in a
middle-aged man. The tumor grew to a great size, and appeared connected with the
perioeteum of the ribs; it ulcerated, sloughed in portions, and finally healed. The patient
remained well for two years, at least.
588 MEDULLARY CANCER.
completed ; about a fourth part of it was left behind, and the wound
was left to heal in the ordinary manner. It healed quickly, inclosing
the remains of the tumor ; but after some time all the appearance of
swelling subsided, and no renewed growth ensued till after a lapse of
three months, when it was renewed, but not more rapidly than before.
A woman's humerus was amputated with a large mass of firm medul-
lary cancer surrounding its neck and the upper part of its shaft. The
same disease existed in all the muscles about. this part of the bone; and
the patient was so exhausted, that the dissection necessary for the re-
moval of the whole disease could not be completed. Large portions of
it were left in the deltoid and great pectoral muscles. In two months
after the operation, however, the wound had very nearly healed, and
no trace could be felt of the masses of the cancer in the muscles. Nor
did any perceptible recurrence take place till more than four months
after the operation. At that time renewed growths appeared at the
scar, and in the thyroid gland, and quickly increased.
To these cases I might add at least three in which I have known
portions of cancerous growths left in the orbit after incomplete opera-
tions ; in all of which complete healing ensued, and one, two, or three
months elapsed before any renewed growth was evident in the portion
of disease that [was left. In all these cases the disappearance of the
cancer may have been due in part to the disease and rapid degeneration
excited in it by the injury of the operation and its consequences ; and
in all, the growth was renewed within three months of the disappear-
ance : a fallacious hope was in all excited, and bitterly disappointed.
But I shall have presently to refer to a case in which the removal of
cancers was independent of local injury.
It is most probable that fatty degeneration coincided with the wasting
and absorption of cancer which occurred in the preceding cases ; for it
seems to be the most frequent change when growth is hindered. I have
already referred to the fatty degeneration which, in medullary cancers,
as in other tumors, may give an appearance of buff or ochre-yellow
lines or minute spots scattered, as a reticulum, through their substance.
I have also described (p. 564) the similar but larger degeneration which
ensues in those portions or lobes of medullary cancers that are found as
tuberculoid masses (phymatoid of Lebert), yellow and half dry, among
the other portions that appear actively progressive. In both cases it
is probable that the altered substances are incapable of further growth ;
but the change, being only partial, does not materially affect the pro-
gress of the whole mass. But though more rarely, a whole mass (espe-
cially when many exist, as in the liver) may be found white, or yellow-
ish-white, soft, partially dried, close-textured but friable, and greasy
to the touch — in a state of what Rokitansky has called " saponifica-
tion." In such cases, many of the cancer-cells and nuclei have the
characters of the granular or fatty degeneration, and may appear col-
DEGENERATION. 589
lapsed and shrivelled ; and they are mingled with ahundant molecular
matter and oil-particles of various sizes, and often with crystals of cho-
leaterine or with colored granules. All the analogies of such changes
in other parts imply that cancers thus degenerated must be incapable
of increase; they are amongst those which may well be called, as by
Rokitansky, obsolete. But I am not yet sure that these gradual
changes have been ever followed by absorption of the altered cancer-
substance, and by healing :* the disease ceases but does not disappear :
and usually, while one mass is thus changing, others are progressive.
The calcarous degeneration is much more rare than the two preceding.
It is fully described by Dr. Bennettf and Rokitansky,! and is in all
essential characters similar to that which so often occurs in degenera-
ting arteries, calcified inflammatory products, &c. The earthy matter,
in minute granules, is commonly mingled with fatty matter, and, ac-
cording to the quantity of fluid, is like more or less liquid or dry and
hardened mortar : if hardened it lies in grains, or larger irregular con-
cretions, in the substance of the tumor. Its indications are the same
as those of the fatty degeneration with which it is usually mingled.§
Among the diseases of medullary cancers their proneness to bleeding
may be mentioned. Hence their occasionally abundant hemorrhages
when protruding, and the frequent large extravasations of blood in
them, variously altering their aspects as it passes through its stages of
decolorization, or other changes. The extreme examples of such bleed-
ing cancers constitute the fungus hsematodes.
Acute inflammation also is frequent, especially in such as are ex-
posed through ulcers. It may produce not only enlargement of the
bloodvessels and swelling of the tumor, but softening, suppuration, and,
I believe, other of its ordinary effects. The softening may be com-
pared with that which occurs in inflammation of any natural part, like
whichy also, it is, I believe, often attended with a rapid fatty degenera-
tion or a disintegration of the cancer-structures. I am not disposed to
think with Rokitansky that the reticulum, or other ordinary yellow
deposits in cancers, are due to inflammatory exudations passing into
and propagating a fatty transformation ; but I think that acute inflam-
mation in a medullary or any other cancer is likely to be attended with
* The supposed cases of healing of cancer of the liver, reported as having occurred at
Prague, admit of other explanations. (See Lebert, Traitb Pratique, p. 72).
f On Cancerous and Cancroid Growths, p. 214.
X Loc cit., p. 352.
{ I have little doubt that the melanotic cancer might be truly described as a pigmental
degeneration of the medullary cancer (except in the few instances in which epithelial can-
cer* are melanotic). But part of another lecture will be devoted to this. The same lecture
will comprise the colloid or alveolar cancer; and I shall have occasion to mention in it the
frequent occurrence of cysts in medullary cancers, some of which might perhaps be de-
scribed as a cystic disease of the cancers.
590 MEDULLARY CANCER.
the same degenerative softening and transformation as we find con-
stituting a part of the inflammatory process in the natural tissues.
Thu^ degenerating, and whether with or without suppuration, a medul-
lary cancer may be completely removed.
By sloughing, also, a medullary cancer may be wholly ejected ; and
this event is more likely to happen than with any other kind of cancer,
because no other is common in the form of an isolable mass. I might
collect several cases in which it has occurried, but none is more remark-
able than this.* A strong man, 46 years old, under Mr. Lawrence's
care, had a large firm medullary cancer deep seated in his thigh, of
about nine months' growth, painful and increasing. In an attempt to
remove it, the femoral artery was found passing right through it ; its
connections, also, appeared so wide and firm, and bleeding ensued from
vessels of so great size, that the operation was discontinued after about
half the surface of the tumor had been uncovered. The tumor sloughed,
and gradually was completely separated. It came away with nearly
three inches of the femoral artery and vein that ran through it. No
bleeding occurred during or after the separation, and the cavity that
remained in the thigh completely healed. The man regained an appa-
rently good health for a few weeks ; then the disease, returning in the
thigh, proved quickly fatal.
In the following strange case, nearly all the methods of spontaneous
temporary cure which I have been illustrating were exemplified :
A tall, healthy-looking man, 36 years old, came under my care in
July, 1850. In October, 1849, he thought he strained his shoulder in
some exertion, and soon after this he noticed a swelling over his right
deltoid muscle. It increased slowly and without pain for nine months,
and was thought to be a fatty tumor, or perhaps a chronic abscess.
About the beginning of July, other tumors appeared about the shoulder;
and, when I first saw him, there was not only the tumor first formed,
which now covered two-thirds of the deltoid, but around its borders
were numerous smaller round and oval masses ; in the axilla was a mass
as large as an egg ; over the brachial vessels lay a series of five smaller
tumors, and a similar series of larger tumors over the axillary vessels
reaching under the clavicle. A small tumor of several years* date lay
at the border of the sterno-mastoid muscle ; and one, which had been
noticed for twelve years, was in the right groin. All these tumors were
soft, pliant, painless, subcutaneous, movable, more or less lobed. There
could be very little doubt that they were medullary cancers, and their
complete removal seemed impossible; but it was advised that, for proofs
sake, one should be excised. I therefore removed one of those near the
chief mass. It was composed of a soft grayish substance, with a pale
purple tinge, lobed, easily reduced to pulp, and in microscopic structure
* The case is fully reported by Mr. Aberncthy Kingdon, in the Medical Gazette, ISM.
TEMPORARY CURB. 591
consisted almost wholly of nucleated cells exactly conformed to the very
type of cancer-cells. The' operation was followed by no discomfort ;
and, a few days after it, the patient left the hospital, still looking
healthy, but, I supposed, doomed to a rapidly fatal progress of the dis-
ease.
At home, near Dover, he was under the care of Mr. Sankey. In a
few days after his return, the skin over the largest tumor cracked, and
a thin discharge issued from it. Four days later he was attacked with
sickness, diarrhoea, and abdominal pain, and in his writhings he hurt
his arm. Next day, three or four more openings had formed over the
great tumor, and the scar of the operation wound reopened : the tumor
itself had rapidly enlarged. From all these apertures pus was freely
discharged, and in a day or two large sloughs were discharged or drawn
through them. With the sloughing, profuse hemorrhage several times
occurred. All the upper part of the arm and shoulder was undermined
by the sloughing, and a great cavity remained, from which, for three
weeks, a thin foetid fluid was discharged, but which then began to heal,
and in twelve weeks was completely closed in.
While these changes were going on in the tumors over the deltoid and
in those near it, that in the axilla was constantly enlarging. It became
^* as large as a hat," and early in September it burst ; and through a
small aperture about six pints of pus were rapidly discharged. A great
cavity, like that of a collapsed abscess, remained ; but it quickly ceased
to discharge, and healed. In the same time all the tumors over the
brachial vessels disappeared ; they did not inflame or seem to change
their texture ; only, they gradually decreased and cleared away, and
with them that also disappeared which had been in the groin for twelve
years.
It need hardly be said that during all this time of sloughing and sup-
puration the patient had been well managed, and amply supported with
food and wine and medicine. About the end of October he appeared
completely recovered, and returned to his work. I saw him again in
January, 1851. He looked and felt well, and, but that his arm was
weak, he was fully capable of work as an agricultural laborer. Over
the lower half of the deltoid there was a large irregular scar ; and this
appeared continuous posteriorly with a small mass of hard tough sub-
stance, of which one could not say whether it were tissues indurated
after the sloughing, or the remains of the tumor shrivelled and hard-
ened : whatever it was, it was painless and gradually decreasing. No
traces remained of the other tumors in the arm, except a small mass
like a lymphatic gland in the middle of the upper arm. In the axilla
there was a small swelling like a cluster of natural lymphatic glands.
The tumor also remained at the border of the sterno-mastoid muscle,
and was rather larger than in July.
In February, 1851, the swelling of the axilla began to increase, its
592 MBDULLART CANCBR.
growth became more and more rapid. Bj the end of March the arm
was greatly swollen ; he suffered severe paiA in and about it ; his health
failed ; he had dyspnoea and frequent vomiting, and died with pleuro-
pneumonia on April 20. The tumor in the axilla (the only one found
after death) was about eight inches long, oval, lobed, soft, vascular, and
brain-like, and consisted, chiefly, of small apparently imperfectly
formed cancer-cells.
Such a case as this needs little comment. It illustrates the spon-
taneous removal, and, so far, the healing, of medullary cancers by ab-
sorption, by inflammation and abundant suppuration, and by sloughing.
It shows the absorption of the cancerous matter, doubtless in an altered
state, accomplished without evident injury to the economy. And it
illustrates the cancerous diathesis quickly re-established after being, we
must suppose, suspended or superseded for a time, during the removal
of its products. Hard, therefore, as we may say, the struggle for re-
covery was, it was not successful.
It is scarcely possible to give general illustrations of the pain and
other phenomena attendant on the progress of medullary cancers ; for
these are variously modified by the many organs in which it may have
its primary seat. The history of some of the medullary cancers, which
grow as distinct tumors, may teach us that the pain is not an affection
of the cancer itself, but of the organ which it occupies. Such cancer-
ous tumors, in the subcutaneous areolar tissue, are, I believe, rarely the
sources of pain ; often they are completely insensible : yet the same
kind of tumors seated among the deeper parts of limbs, or inclosed in
the testicle, or in bone, seem to be usually painful, and often severely
so. The difference indicates that the varying pain is not of the cancer,
but of the part it fills.
The cachexia is, in the later periods of the disease, too much varied
by the disturbed functions of the organs specially affected to admit of
general description. But it is chiefly in this form of cancer that, early
in the disease, and even while the local affection seems trivial, and in-
volves no important part, we often find the signs of the general health
being profoundly affected ; the weight and muscular power regularly
diminishing, the complexion gradually fading, the features becoming
sharper, the pulse and breathing quicker, the blood more pale. Such
events are, indeed, inconstant, both in the time of their occurrence and
in their intensity ; but in many cases they are far too striking to be
overlooked ; the defective nutrition of the early stages of phthisis is
not more marked : the evidence is complete for the proof of a distinct
cancerous cachexia, which is indeed commonly indicated and may be
measured by a cancerous growth, but which may exist in a degree, with
which neither the bulk, nor the rate of increase, of the growth is at all
commensurate.
, To estimate the general duration of life in those who have medullary .
DURATION OF LIFE. 593
cancerSy those cases alone should be reckoned in which parts whose
functions are not essential to life are affected ; such as the bones and
soft parts about the trunk and limbs, the testicle, the eye, and other
external organs. From a table of fifty cases of medullary cancers in
these parts (including eight cases of cancer of the bones by M. Lebert),
in all of which the disease pursued its course without operative inter-
ference, I find the average duration of life to be rather more than two
years from the patient's first observation of the disease.*
Among 45 of these patients,
6 died within 0 months.
7 <* between 6 and 12 months.
11 *» « 12 " 18 "
4 « u |g t( 24 "
7 u tt 24 " 36 "
7 " « 36 " 48 "
3 " more than 48 months from the commencement of the disease.
A comparison of this table with that at p. 555 will show, in striking
contrast with the history of scirrhous cancer, the rapidity of this form
in running its fatal career ; a rapidity which is certainly not to be
ascribed to the earlier exhaustion produced by hemorrhage, discharge,
pain, or other local accidents of the disease, but is mainly due to the
augmenting cachexia. The same comparison will show how small is
the proportion of those in whom the disease lasts more than four^ years ;
and there seem to be no cases parallel with those of scirrhous cancer
which are slowly progressive through periods of five, ten, or more years.
I have mentioned instances of the apparent suspension of the disease ;
but these are different from the cases of constant slow progress, the
rarity of which supplies an important fact in diagnosis, in the great
probability that a tumor is not a medullary cancer, if it have been in-
creasing for more than three years without distinct manifestation of its
cancerous nature.
The effect of removing medullary cancers is, on the whole, an in-
creased average duration of life ; but chiefly, I believe, because in a
few cases the operation is long survived, and, in some, death, which
would have speedily ensued, is for a time arrested. Thus in forty-six
cases in which external medullary cancers were removed by excision,
or amputation of the affected part, the average duration of life was
something more than twenty-eight months.f Among fifty-one cases
(including nine cases of extirpated cancer of the eye, from M. Lebert),
* I have not reckoned in this table the exceptional cases referred to at p. 586, in which
the disease appears to have been suspended for some years. But I have included five
cases in which the patients were still living beyond the average time. In the forty-five
already dead, the average duration of life was 23.8 months.
f Two of Mr. Baker's tables show a greater advantage derived from operations, probably
because of a better selection of cases. The average duration of life in 32 cases not sub-
mitted 10 opeiation was 20 months ; in 16 cases operated on, 33.4 months.
Within
6
months,
• •
Between
6 and 12 months,
u
12
" 18
u
i(
18
" 24
t(
u
24
« 36
u
tt
36
" 48
C(
Above
48
4(
594 MEDULLARY CANCER.
these were the several times of death, reckoning, as before, from the
first observation of the disease bj the patient
1
13
7
8
11
3
8
The comparison of this table with that on p. 593 will show that the
only notable contrast between them is in their first and last lines.
If the operation be recovered from, the regular course of events
brings about the renewal of cancerous growth, either near the seat of
the former growth, or in the lymphatics connected therewith, or, more
rarely, in some distant part. In thirty-eight cases of medullary cancer,
affecting primarily the same external organs as afforded the cases for
the former tables, I find the average period of recurrence after the
operation to have been seven months. I have reckoned only those cases
in which a period of apparent recovery was noted after the operation;
all those cases are omitted in which the disease was not wholly removed,
or in which it is most probable that the same disease existed unobserved
in lymphatics or other internal orgfins at the time of operation. Yet
the average rate of recurrence is fearfully rapid.
It was observed in between
1 and 3 months in 18 cases.
3 " 6 « 11 "
6 " 12 " 4 "
12 " 24 " 3 "
24 " 36 " 2 ''
Among the fifty-one cases in the first table above, those of five pa-
tients are included, who were living without apparent return of disease,
for periods of three, three and a half, four and a half, five, and six
years after operation ;. and I have referred already to one case in which
a patient died with cancer in the pelvis twelve years after the removal
of a testicle which was considered cancerous. Of cases more near to
recovery than these I can find no instances on authentic record.
The cases I have been able to collect supply little that is conclusive
respecting the different durations of life, according to the age of the
patient, the seat of the cancer, and other such circumstances. In chil-
dren under ten years old, the average duration of life, with medullary
cancers of external parts, is, I believe, not more than eighteen months;
after ten years, age seems to have little or no influence. According to
the part affected the average duration of life appears to be greater in
the following order : the testicle, the eye, the bones, the soft parts of
the limbs and trunk, the lymphatics ; but the difference is not consider-
DURATION OF LIFB. 595
able. It is the same, I believe, with the results of operations ; recur-
rence and death occur, on the whole, more tardily after amputations for
medullary cancers of the bones and soft parts of the limbs, than after
extirpations of the eye or testicle ; but there are many obvious reasons
why we cannot hence deduce more than a very unstable rule for prac-
tice. The previous duration of the disease seems, also, to have little
influence on the time of recurrence after the operation : the only gene-
ral rule seems to be, that the rapidity of recurrence corresponds with
that of the progress of the primary disease.
Now, respecting the propriety of removing a medullary cancer in any
single case, much that was said respecting the operation for scirrhous
cancer of the breast might be repeated here. The hope of finally curing
the disease by operation should not be entertained. Such an event may
happen, but the chance of it is not greater than that of the disease
being spontaneously cured or arrested ; and the chance of any of these
things is too slight to be weighed in the decision on any single case.
The question, in each case, is whether life may be so prolonged, or its
sufferings so diminished, as to justify the risk of the operation. In
general, I think, the answer must be affirmative wherever the disease
can be wholly removed, and the cachexia is not so manifest as to make
it most probable that the operation will of itself prove fatal.
(1.) The number of cases in which the patients survive the operation
for a longer time than that in which, on the average, the disease runs
its course, is sufficient to justify the hope of considerable advantage
from the removal of the disease. On the other hand, the number of
chronic cases of medullary cancer is so small, that no corresponding
hope of a life being prolonged much beyond the average can be reason-
ably held, if the disease be left to run its own career. "*"
(2.) The hope that the removal of the cancer will secure a considera-
ble addition (two or more years, for example,) to the length of life will
be more often disappointed than fulfilled. But, even when wc do not
entertain this hope, the operation may be justified by the belief that it
will avert or postpone great suffering. The miseries attendant on the
regular progress of a medullary cancer, in any external part, are hardly
less than those of hard cancer of the breast ; they are such, and in
general so much greater than those of the recurrent disease, that unless
it is very probable that an operation will materially shorten life, its
performance is warranted by the probability of its rendering the rest
of life less burdensome.
(3.) A motive for operation in cases of supposed medullary cancers
may often be drawn from the uncertainty of the diagnosis. This is
* The difierence here stated may seem opposed by the tables in the foregoing pages. I
ID11SC thexeiore state that, at page 586, I have referred to all the cases of chronic or sus-
pended medullary cancer that I have ever seen or heard of; but that the cases of operations
curviTed Sbr more than three years, mentioned at page 504, were not selected on this
aooomrt, but occurred in the ordinary course of observation.
596 EPITHELIAL CANCER.
especially the case with those of the large bones, for the removal of
which the peril of the necessary operation might seem too great for the
probability of advantage to be derived from it. I have referred to
cases of cartilaginous and myeloid tumors of bone (pp. 443, 463, 466),
in which during life the diagnosis from medullary cancers was, I be-
lieve, impossible. In all such cases, and I am sure they are not very
rare, the observance of a rule against the removal of tumors or of bones
believed to be cancerous, would lead to a lamentable loss of life. All
doubts respecting diagnosis are here to be reckoned in favor of opera-
tions.
LECTURE XXXII.
EPITHELIAL CANCER.
PART I. — ANATOMY.
Epithelial cancer has its primary seat, with very rare exceptions,
in or just beneath some portion of skin or mucous membrane. Its most
frequent locality is the lower lip, at or near the junction of the skin
and mucous membrane ; next in order of frequency it is found in the
tongue, prepuce, scrotum (of chimney-sweeps), labia, and nymphs:
more rarely it occurs in very many other parts, — as at the anus, in the
interior of the cheek, the upper lip, the mucous membrane of the palate,
the larynx, pharynx, and cardia, the neck and orifice of the uterus, the
rectum and urinary bladder, the skin of the perineum, of the extremi-
ties, the face, head, and various parts of the trunk. In the rare
instances of its occurrence, as a primary disease, in other than integn-
mental parts, it has been found in the inguinal lymphatic glands (as in
a case which I shall relate), in bones,* the dura mater, and in the
tissues forming the bases or walls of old ulcers.
By extension from any of its primary seats, an epithelial cancer may
occupy any tissue : thus, in its progress from the lip, tongue, or any
other part, muscles, bones, fibrous tissues, are alike invaded and de-
stroyed by it. As a secondary disease, or in its recurrence after re-
moval by operation, it may also have its seat in any of these tissues at
or near its primary seat ; but it more commonly affects the lymphatic
glands that are in anatomical connection therewith ; and, very rarely,
it has been found in internal organs, the lungs, liver, and heart.f
* Virchow, in the WOrzburg Verhandlun^en, i, 106.
t In the lungs and in the heart, in the Museum of St. Bartholomew's. In the liver once,
by Rokitansky (Pathol. Anat., i, 380). In the lungs and in the liver, in the Museume of
Berlin and WQrzburg (Virchow, I. c. ; and in his Archiv, B. iii, p. 222). Ch. Robin has
described, under the title epithelioma of the kidney (Gaz. des Hop., 1855), a wcll-roarkefl
ANATOMY — STRUCTURE. 597
The essential aDatomical character of the epithelial cancer is, that it
is chiefly composed of cells which bear a general resemblance to those
of snch tessellated or scalj epithelium as lines the interior of the lips
and mouth,* and that part of these cells are inserted or infiltrated in the
interstices of the proper structures of the skin or other affected tissue. f
The epithelial cancers of the skin or mucous membrane from which,
as types, the general characters of the disease must be drawn, present
many varieties of external shape and relations, which are dependent,
chiefly, on the situation in which the cancerous structures are placed.
They may be either almost uniformly diffused among all the tissues of
the skin or mucous membrane, predominating in only a small degree in
the papillae ; or the papillae may be their chief seat ; or they may oc-
cupy only the subintegumental tissues. As a general rule, in the first
of these cases, the cancer is but little elevated above or imbedded below
the normal level of the integument, and its depth or thickness is much
less than its other dimensions ; in the second, it forms a prominent
warty or exuberant outgrowth ; in the third, a deeper-seated flat or
rounded mass. These varieties are commonly well marked in the first
notice of the cancers, or during the earlier stages of their growth ; later,
they are less marked, because (especially after ulceration has com-
menced) an epithelial cancer, which has been superficial or exuberant,
is prone to extend into deep-seated parts ; or one which was at first
deeply seated may grow out exuberantly. Moreover, when ulceration
is in progress, a greater uniformity of external appearance is found ;
for, in general, while all that was superficial or exuberant is in process
of destruction, the base of the cancer is constantly extending both
widely and deeply into the subintegumental tissues.
I believe that it will be useful to describe separately the external
case of epithelial cancer of the kidney, but under the same title he describes a case which
appears to have been nothing more than blocking up with epithelium and dilatation of the
urine tobes. In a case described by Mr. Sibley in tlie Path. Trans., vol. x, p. '^^2y in which
the tongue was .affected with epithelial cancer, a post-mortem examination disclosed a
peculiar condition of the right supra-renal capsule. It was enlarged and converted into a
firm, almost fibrous-looking, cream-colored substance, in which ** large numbers of cells,
cloaely resembling epithelial cancer-cells, were found." The other viscera were healthy.
* In very rare cases the cells, or part of them, are like those of columnar epithelium.
f In assigning these two conditions as the essential characters of epithelial cancers —
namely, both the construction with epithelial cells, and the insertion of such cells among the
original, though oAen morbid, textures of the affected part — I make a group of diseases less
comprehensive than either the " Cancroid'* of Lebert and Bennett, or the " Epithelioma" of
Hannover. These excellent pathologists, and many others following them, would abolish
altogether the name of epithelial cancer, and place the cases which are here so designated
in a fcroop completely separate from cancers, as exemplified by the scirrhous and medullary
forms. It is not without much consideration that I have decided to differ from such authori-
ties; but I believe that the whole pathology of the diseases in which the two characters above
cited are combined is, with rare exceptions, so closely conformed to that of the scirrhous and
medullary cancers, that they should be included under the same generic name. The grounds
of this belief^ which, I think, agrees with the opinions of Rokitansky and Virchow, will ap-
pear in the present lecture; and at its end I will briefly sum them up.
598 SUPERFICIAL EPITHBLIAL CANCBR.
characters of the two principal varieties of epithelial cancer of the in-
teguments here indicated ; and (while remembering that mingled, transi-
tional, and intermediate specimens may be very often seen), to speak
of them as the superficial or outgrowing, and the deep-seated, forms of
the disease.*
Among the examples of the superficial epithelial cancers, the greater
part derive a peculiar character from the share which the papillse of the
skin or mucous membrane take in the disease. These being enlarged,
and variously deformed and clustered, give a condylomatous appear-
ance to the morbid structures, which has led to their being called papil-
lary or warty cancers, and which renders it sometimes dilQScuIt to
distinguish them from common warty growths. According to the
changes in the papillae, numerous varieties of external appearance may
be presented : I shall here describe only the chief of them.
In the most ordinary examples of epithelial cancer of the lower lip,
or of a labium, or of the scrotum in the soot-cancers, if they be ex-
amined previous to ulceration, one can feel an outspread swelling, and
an unnatural firmness or hardness of the affected skin. The width and
length of the swelling are much greater than its thickness. The diseased
part is enlarged ; the lip, for example, pouts, and projects like one
overgrown ; and the swelling is slightly elevated, rising gradually or
abruptly from its borders, and having a round or oval or sinuous out-
line. Its surface, previous to ulceration, may be nearly smooth, but
more often is coarsely granulated, or tuberculated, or lowly warty, like
the surface of a syphilitic condyloma, deriving this character usually
from the enlarged and closely clustered papilloe. The surface is gene-
rally moist with ichorous discharge, or covered with a scab, or with a
soft material formed of detached epidermal scales. The firmness or
hardness of the diseased part is various in degree in different instances:
it is very seldom extreme ; the part, however firm, is usually flexible
and pliant, and feels moderately tense and resilient on pressure. Com-
monly, it is morbidly sensitive, and the seat of increased afllux of blood.
Its extent is, of course, various ; but, before ulceration, the disease
makes more progress in length and breadth than in depth ; so that
when, for example, it occupies the whole border of a lip or of a labiam,
it may not exceed the third of an inch in thickness.
In the form of epithelial cancer just described there may be no
* I believe that either of these forms may occur in any of the parts enumerated as the
usual seats of epithelial cancer ; but they are not both equally common in every such part
The superficial, and especially those which have the characters of warty and cauliflower-
like outgrowths, are most frequently found on mucous surfaces, especial those of the genitti
organs ; the deep-seated are more frequent in the tongue than elsewhere ; those on the ex-
tremities and in the scrotum have usually a well-marked warty character, and are rarely
deep-seated. Other particulars might, I believe, be stated, but I am imwilling to state them
unsupported by counted numbers of cases.
VAEIETIE8. 5yy
conuderable enlargement of papillse, or it may onl; appear when the
growth is cut through. But, in many instances (especially, I think, in
the epithelial cancers of the prepuce, glands, and integuments of the
extremities), the changes of the papillie are much more evident. In
some, aeintheadjacent sketch, one sees a great extent of surface covered
with crowds and clusters of enlarged papillse set on a level or slightly
Fig. B8.-»
elevated portion of the cutis. Singly (when the ichor and loose scales
that fill their intervals are washed away), they appear cylindriform,
flask-shaped, pyriform, or conical ; clustered, they make nodulated and
narrow-stemmed masses. They may be in one or in many groups ; or
groaps of them may be scattered around some large central ulcer. They
appear yery vascular, and their surface, thinly covered with opaque-
white cuticle, has a pink, or vermilion, or brightly florid hue.f
In other instances, or in other parts, a large mass is formed, the sur-
face of which, when exposed by washing away the loose epidermoid
cells which fill up its inequalities, is largely granulated or tubcrculated,
and is planned out into lobes by deeper clefts. Such growths arc up-
raised, cauliflower-like; and, with this likeness, may be broken through
the clefts, into narrow-stemmed masses, formed each of one or more
close-packed groups of enlarged, tuberous, and clavate papillse.J The
surface of anch a growth shows, usually, its full vascularity ; for if it be
washed, it appears bare, and, like the surface of common granulations,
has no covering layer of cuticle. It may be florid, bleeding on slight
contact, but, more often, it presents a dull or rusty vermilion tint, rather
* The papillarf chancier is well slio'
the Haieani ofSt. Banholomsw's (Ser. i.
of Ifae esM is in Pon'i Works by Earle, iii.
emplored in Btrewing nol Tor aeveral mo
t Hateunt or St. Bartholomew's, Ser. J,
3301, 3607, 360S,&o.
t Mmeam of St. Bartliolomew's, Sei. xzx, 3S. Mut. Coll. Surg, 3809.
wn ir
1 the epecimei
lOf
M>ol-can(
'cr of the liB
md, in
i,6),
wiiich ii repr
ewn
led in Fi
ig. 98. Thel
lislory
,183.
The patient
1 R garde
ner, who bad been
tning
>: iliediwnaf
a or five
yean' duraii
43,1
136, 127, Ac., 1
mJ
Ser. li. e
. Mus. Coll.
Surg.
600 SUPERFICIAL EPITHELIAL CAHCKR.
than the brighter crimson or pink of common grannlationa, or of each
warts as one commonlj sees on the prepuce or glans penis.
Occasionallj, we meet with an epithelial cancer having the shape of
a sharply bordered circular or oval disk, upraised from one to three
lines above the level of the adjacent Bkin or mucous membrane, and im-
bedded in about the same depth below it. The surfaces of snch disk-
shaped cancers are usually flat, or slightly concave, granulated, spongy,
or irregularly cleft ; their margins are bordered by the healthy integu-
ments, raised and often slightly everted by their growth. Such shapes
are not unfrequent among the epithelial cancers of the tongue, of the
lining of the prepuce, and of the scrotum. I removed such a one also
from the perineum, and have seen one in the vagina.
Sometimes, again, an epithelial cancer grows out in the form of a
cone. I examined such a one removed from the lower Up, which was
half an inch high, and nearly aa much in diameter at its base. Its base
was a cancerous portion of cutis ; its substance was firm, gray, com-
posed of the usual elements of epithelial cancers imbedded among the
connective tissue outgrown from the skin ; the subcutaneous tissue wss
healthy. In another instance an exactly similar cancer grew on a chim-
ney-sweep's neck;* and, in both these cases, the growth being covered
with a thick laminated black and brown scab, was, at &rst, not easy to
distinguish from syphilitic rupia : that in the neck might even have
been confounded (as some, I believe, have been) with one of the Aorm
that grow from diseased hair follicles. Mr. Curlingf describes a simi-
lar growth three quarters of an inch long, on the scrotum of a chimney-
sweep ; and has copied, from one of Mr. Wadd's sketches, a representa-
tion of a horn two and a half inches long similarly formed.
Lastly, we may find epithelial cancers as narrow-stemmed or eveo
pendulous growths from the cutis. I have seen such
on the lower lip, and at the anus, like masses of very
firm exuberant granulations, two inches in diameter,
springing from narrow bases in the cutis, or deeper
tissues, and far overhanging the adjacent healthy skin.
And I lately examined one of this kind, which was
removed from the skin over the lower border of the
great pectoral muscle. It was exactly like the apeci-
mcn sketched in Fig. 99. It was spheroidal, abont
an inch in diameter, rising from the skin with a base
CI jreat
theaar
ne paiieri
It waa in the hoapilal
with
Ulcerous
wBttoriht
+
Trealis.
■ nn DisPB!
les of the Tp?licte, p
. 5-J5.
The;.
perimen
i> in Ihe Mu).
Coll. SoTg.,
IC
9. In the
Museum i.
ifSl, BarlMomewi
nsiance
of very h
liich,
tl
le bonlet
sofiheulc
et. there are spur-d.,
,ped«i
iarp.poi
inted pro
::easc9, doubt le:
iBcanceioui
,p
illre, som
e of which
are from J to j nn .
inch >r>
t
Fig- 09.
Section .
□fanairou'-basedoi
jigrow
ing cpi
thelial CI
ancer. Ii was
. Fxirei
nelr
in
:iilar, Rm
1 bR.I Broi*
■n in ihe piace of a
daili n
lole, ot
pigmentary ncevus, on
ibew.
ill of
*•
abdomen
1. Two gtowilii had been pre
viously remoi
■ed from
Ihe same part.
EXTERNAL CHARACTERS. 601
about half as wide ; it was lobed, deeply fissured, and subdivided like
a wart, with its component portions pyriform and mutually compressed.
Its surface was pinkish, covered with a thin opaque- white cuticle, which
extended into and seemed to cease gradually in the fissures. Its sub-
stance, composed almost wholly of epithelial cancer-cells, was mode-
rately firm and elastic. It was but little painful. A thin, strong-
smelling fluid oozed from it. The patient had noticed a small un-
changing wart in the place of this growth for ten or twelve years.
Without evident cause it had begun to grow rapidly, and had become
redder and discharged fluid, six weeks before its removal.'*'
It is almost needless to say that a much greater variety of shapes
than I have here described may be derived from the difierent methods
and degrees in which the papillae are deformed, enlarged, and involved
in the cancerous disease. All, and more than all, the shapes of common
warty and condylomatous growths may be produced. But the same
general plan of construction exists in all ; namely, a certain portion of
the skin or mucous membrane is infiltrated with epithelial cancer-struc-
tures : on this, as on a base more or less elevated and imbedded, the
papillsd, variously changed in shape, size, and grouping, are also can-
cerous ; their natural structures, if we except their bloodvessels, which
appear enlarged, are replaced by epithelial cancer-cells. And herein
is the essential distinction between a simple or common warty or papil-
lary growth, and a cancerous one or warty cancer. In the former the
papillse retain their natural structures ; however much they may be
multiplied, or changed in shape and size, they are either merely hyper-
trophied, or are infiltrated with organized inflammatory products;
however abundant the epidermis or epithelium may be, it only covers
and ensheaths them. But in the warty cancer the papillae are them-
selves cancerous : more or less of their natural shape, or of the manner
of their increase, may be traced ; but their natural structures are re-
placed by cancer structures ; the cells like those of epithelium lie not
only over, but within, them.f
* The caaliflower ezcreacence of the uterus may be most nearly compared with the ex-
tremely exuberant epithelial cancers such as are described above (see p. 620).
f I described the papillary origin and construction of these cancers in 1838 (Medical Ga-
zette, xxiii, 284), but was not then aware of their minute structure. Later examinations
hsTe made me sure that the true distinction between them and other papillary growths is
as aboTe stated. But it is to be observed that cancerous growths may appear papillary or
warty, though no original papilise are engaged in their formation. Thus when papillary
cancers are deeply ulcerated at their centres, the base of the ulcer, where all the original
papillse are destroyed, may be warty, like its borders where the cancerous papiiUp are evi-
dent. Some of the most warty-looking epithelial cancers are those which grow from the
deep tiflsnes of the leg after old injuries. This may be only an example of cancerous
growths imitating the construction of adjacent parts; but in some instances (as in cysts, and
on the mucous membrane of the gall-bladder and stomach), the warty cancers are probably
ezamples of the dendritic mode of growtli. It must also be a question, at present, whether
39
exutwniDi MiKcn of ibt >kin are not lo be wetibad u lUi iWb^
fj ihe Iran, exiTomvly dlAculi lu mat ihfir ori||)ii Ann
go? BPITHBLIAL OAROIB.
To ileHcribe the interior Btr'ucture of the superficial csncerou* grovtbi
we may tnke as type? the most common examplos of canccncf lb
lower lip, — those in which the papillie are indeetl involvwl, enktfri,
And cancerous, but not so as to form distinct or very pronunmt <m-
growths.
The surface of » vertical section through such a canot^ ceamoalj
presents, at its upper border, either a crust or scab, fomed of iAu,
detached scales, and blood ; or else a layer of detAchoi) cpiilenMij
scales, forming a white, crumbling, paaty substance. This UYeroij
be imperceptible, or extremely thin; hut it may be a linv or ■tonii
thickness ; and it enters all the inequalities of the »nrfacv on vlud ii
lies. Its cells or scales are not regularly tesscllatod or infaricsioL
like those of the epidermis on a common wart, but are placed ■iibwi
order, loosely connected both with one another and witli the •ubjuw
vascular structures, and may be easily washed away.
Such a layer must be regarded, I presume, as formed of qiiUiilitI
cancer-cells, detached or desquamated from the subjacent Taacnhtui
more perfectly organized suhatancc of the cancer. This euWtaaei fn-
scnts, in most cases, or in most parts, a grayish or grayish-whit« coltf^
and shines without being translucent. It is firm and reailinit, tltw-
textured, and usually void of any appearauce of regularly lobed, piM-
lur, or fibrous construction, except such as may exist near itx ■w6cr,
where close-set and uniformly elongated vertical papillsu may make it
look striped. The grayness and firmness are, I think, the nore uifvm
and decided the slower the growth of the cancer has been. In the •*■»
cases, especially of secondary formations, or when the cannir hMtm
inflamed, or ulceration is iu quick progres-s the cut surface ■■ft*
opaque-white, or of some dull yellow or ochro tint, streaked mi
blotched with blood; or it may, iu similar coses, be soft and ihndlf,
or nearly brain-like; but these appearances are very rare.
The gray substance of epithelial cancers commonly yield* to fomat
only a small quantity of turbid yellowish or grayish fluid: batvilk
rare exceptions, one may squeeze or scrape from certain parts of iW
cut surface, as if from small cavities or caniils, a peculiar opaqne-wkm
or yellowish material. It is like the comedones, or accumulated tjilAt-
lial and sebaceous contents of hair follicles; or even more likevkii
one may scrape from the epidermis of the palm or sole after long Baw-
ration or putrefaction. This material, which is composed of atnwnm
essentially similar to those of the firmer substance of the cancvr, ba
differently aggregated, supplies one of the best characteristic I'f ^
disease. It may be thickly liquid, but more often is like a soft, b»I^
dry, crumbling, curdy substance : pressed on a smooth surface, it ioo
not become pulpy or creamy, but smears the surface, aa if it wmt
INTERNAL STRUCTURE. 608
greasy : mixed with water, it does not at once diffuse itself, so as to
make the water uniformly turbid, but divides into minute visible parti-
cles, ♦
The quantity of this softer material is extremely various in different
instances of epithelial cancer. According to its abundance and ar-
rangement, the gray basis-substance*may appear differently variegated ;
and the more abundant it is, the more does the cancer lose firmness,
and acquire a soft, friable, and crumbling texture. In many cases the
soft substance appears, on the cut surface, like imbedded scattered dots,
or small grains : these being sections of portions contained in small
cavities. But, as the quantity increases, and the cavities containing it
augment and coalesce, so the firmer substance becomes, as it were, Cri-
briform ; or when the softer substance is washed away, it may appear
reticulated or sponge-like, or as if it had a radiated or plaited struc-
ture. Or, lastly, the soft substance may alone compose the whole of
the cancer : but this, I think, is very rarely the case, except in second-
ary formations and in the lymphatic glands.
Vertical sections of the more exuberant and the more distinctly pa-
pillary epithelial cancers present essentially the same appearance as I
have just described. The upper border, corresponding with the exposed
part of the growth, may be overlaid with thin scab, or crust, or epider-
moid scales, detached and disorderly, or may be bare, like that of a
section of common granulations. The cut surface is generally gray,
succulent, and shining, with distinct appearances of vascularity. Por-
tions of it may yield the peculiar soft crumbling substance like mace-
rated epidermis ; but this is, I think, generally less abundant than in
the less exuberant and deeper set specimens, and is more often arranged
in a radiated or plaited manner.
The vertical sections of the superficial epithelial cancers of the in-
' teguments display many important differences, in relation to the depth
to which the cancer-structures occupy the proper tissues of the skin or
mucous membrane.
In some, only the papillae, or the papillse and the very surface of the
tissue on which they rest, appear to be involved. The enlarged papillae
in such cases usually retaining their direction and their cylindrical or
slenderly conical shape, appear like fine gray stripes or processes ver-
tically raised on the healthy white tissue of the integument, or on its
surface rendered similarly gray by cancerous infiltration. And the out-
lines of the papillae are commonly the more marked because of their con-
trast with the opaque-white substance formed by the epidermoid scales
which cover them and fill up all the interstices between them. In such
* In tbeee are its distinctions from the "juice" of either seirrhous or medullary cancers.
But it must be remembered that, in the rare instances in which epithelial cancers are very
soft, they may yield a creamy or turbid grayish fluid. It can hardly be necessary to give a
caution against oonfbanding the peculiar material described above with that which may be
preaiad (kom mitk-dncts involved in scirrhous cancers (compare p. 528).
604 SUPERFICIAL EPITHELIAL OANOER.
cases the cancerous material mav be more abundant on the surface than
in the substance of the papillae or corium ; and often the whole morbid
substance is brittle, and may be separated from the corium which bears
the papillae.
But more frequently, and almost always in such cases of epithelial
cancers when they are removed in operations, the cancerous structures
are more deeply set. They occupy the whole thickness of the integu-
ment, or reach to a level deeper than it. The base or lower border of
the diseased mass rests on, or is mingled with, the subcutanedus or sub-
mucpus tissues, whatever these may be, — fat, muscular fibres, or any
other. The lateral borders usually extend outwards for some distance,
on each side, beneath the healthy integument which bounds the upraised
part of the diseased growth, and which is usually raised and everted so
as to overhang the adjacent surface. In nearly all these, also, while
the surface and central parts of the cancer are being destroyed by
ulceration, its base and borders are, at a greater rate, extending more
deeply and widely in the subcutaneous or submucous tissues.
The bases of the most exuberant and most distinctly papillary can-
cers are rarely, in the early periods of their growth, either deeply or
widely set in the integument. They rarely, I believe, occupy more
than the thickness of the portion of the skin or mucous membrane from
which the growths spring : they sometimes occupy less. But, in their
later growth, and especially when ulceration is progessive, the same
deeper and wider extension of the base of the cancer ensues as I men-
tioned in the last paragraph.
All the foregoing description will have implied that the proper
structures of the diseased parts are mixed up with the cancer-structures
inserted among them : the condition of parts is here exactly comparable
with that of other cancerous infiltrations. (Compare p. 523.) The
boundaries of the cancer, as seen in sections, usually appear to the
naked eye well-defined ; yet it is often easy to see portions of the
natural tissues extending into it, these being continuous with those
portions among which the cancer-structures are infiltrated. This is
especially evident when, as in the lip or tongue, the superficial muscular
fibres are involved. Pale red bands may then be traced into or within
the cancer ; and the microscope will prove, if need be, their muscular
structure. Or, when these cannot be traced, yet we may find the con-
nective tissue of the involved skin or mucous membrane.
Concerning the changes that ensue in the tissues thus involved in the
deeper parts of epithelial cancers, I believe that what was said of those
in cancerous breasts (p. 523 and 529) might be here nearly repeated,
regard being had to the original difierences of the tissues in the respec-
tive cases. In general, the natural structures in these cases appear not
to grow ; gradually, but not all at the same rate, they degenerate and
are removed, till their place is completely occupied by the increasing
cancer-structures, and an entire substitution is accomplished. So, too,
DEEP-SEATED EPITHELIAL CANCER. 605
what was said of the stroma of scirrhous cancers of the breast might be
repeated. These epithelial cancers have no stroma of their own ; their
proper structures are sustained by the remains of the original textures
of the affected part. And, as in the scirrhous cancers, so in these ;
when they grow very quickly, they occupy a comparatively small area
of the original tissues, and may appear like nearly distinct tumors.
In the most exuberant epithelial cancers, and in those that are pro-
minent, like warts or condylomata, there is more growth of the natural
tissues ; those, not of the papillae alone, but of the basis of the skin or
mucous membrane, may be traced into the outgrowth, forming a stroma
for the cancer-structures, and surmounted by the cancerous papillae.
Such a stroma may be well traced in many soot-cancer warts : the con-
nective tissue extends from the level of the cutis, in vertical or radiating
and connected processes among which the cancer-cells lie; and one may
compare them with the osseous outgrowths that form an internal skele-
ton of a cancer on a bone (see p. 566).
The tissues bordering on the superficial epithelial cancers appear
generally healthy, but they are often increased in vascularity, and
saccnlent. The adjacent corium also may appear thickened, with its
papillae enlarged, and an unusual quantity of moist opaque-white cuticle
may cover them.* This condition is, however, not frequent; neither is
it peculiar to the environs of cancer ; changes essentially similar are
often observed around chronic simple ulcers of the integuments.f
The deep-seated epithelial cancers remain to be described. In the
progress of all the preceding varieties of the superficial form of the
disease, especially when their surfaces are ulcerating, we may trace a
constant subintegumental extension of their bases, in both width and
depth ; an extension which is more than commensurate with the de-
struction at the surface, and in the course of which no tissue is spared.
Now, the same cancerous infiltration of the subcutaneous or submucous
tissues, which is thus the common result of the extension of the disease
from the surface, may also occur primarily : that is, the first formation
of epithelial cancers may be in masses of circumscribed infiltration of
the tissues beneath healthy skin or mucous membrane. The same
condition is more frequent in the epithelial cancers that form, as re-
currences of the disease, near the seats of former operations, or, as
secondary deposits, about the borders of primary superficial growths.
In comparison with the superficial form, the primary deep-seated
* M. Lebert (Trait^ Pratique, p. 618) quotes from M. Follin, that the tissues around the
diseate are often "infiltrated with epidermis in a diffuse manner."
f On some of the diseases of the papillae of the cutis (Medical Gazette, vol. xxiii, p. 285).
The multiform appearances of epithelial cancers which I have described may be still more
▼mried by the consequences of degeneration and disease. But ii would be too tedious to
describe them minutely, while, as I believe, they are essentially similar to the consequences
of the same aJBTections in the scirrhous and medullary cancers, or which I have already given
some acoooDt.
606 GENERAL CHARACTERS.
epithelial cancer is a very rare disease ; yet it is frequent enough for
me to have seen, within the same year, three cases, which I will de-
scribe ; for they were all well-marked examples.
A chimney-sweep, 32 years old, died suddenly, suffocated, in the
night after his admission into St. Bartholomew's.
He had had cough for six months, and aphonia and dyspnoea for two
months. A scrotal soot-cancer had been removed from his brother in
the previous year.
I found a wide-spread layer of firm substance, exactly like that of
the majority of epithelial cancers, under the mucous membrane of the
larynx, involving the left border of the epiglottis, the left arytenoid
cartilage, the intervening aryteno-epiglottidean fold, part of the right
arytenoid cartilage, and the upper and posterior third of the left ala of
the thyroid cartilage. In all this extent, the diseased substance lay
beneath the mucous membrane, which, though very thinly stretched
over some parts of it, appeared healthy, was covered with ciliated epi-
thelium wherever I examined it, and could everywhere be separated in
a distinct layer. "*" All the submucous tissues were involved ; the carti-
lages, as it were buried in the growth, appeared less changed than the
softer parts. The surface of the growth, as covered with the mucous
membrane, was lowly lobed, or tuberculated, raised from one to two
lines above the natural level ; its border was in many parts sinuous.
The cancerous substance was firm, elastic, compact, grayish and white,
shining, variously marked on its section with opaque- white lines. It
appeared wholly composed of the usual minute structures of epithelial
cancers, including abundant laminated epithelial capsules. All the
epithelial structures were of the scale-like form, though collected in the
tissues under a membrane covered with ciliated epithelium.
A man was admitted into the hospital, in a dying state, with a large
firm swelling between the lower jaw and the hyoid bone, the increase of
which had produced great diflSculty of breathing and swallowing. After
his death, the greater part of the swelling was found to be due to cancer
of the deep tissues of the tongue, and of the fauces and lymphatic glands.
A section of the parts (as in Fig. 100) showed that the muscular and
other structures of the posterior two-thirds of the tongue were completely
occupied by a firm cancerous infiltration: but the mucous membrane of
the tongue was entire ; its various papillary structures were healthy and
distinct ; it was only tight-stretched and adherent on the surface of the
cancer. From the base of the tongue the cancer extended backwards
and downwards on both sides of the fauces, and as far as the vocal cords,
preserving in its whole extent the characters of a massive infiltration of
all the submucous tissues. It was covered with healthy-looking mucous
membrane in every part, except just above the right vocal cord, where
* The specimen, and tliose referred to in the two following cases, are in the Museum of
St. Bartholomew's.
BPITHKLIAL CAKCES — DLCERATION.
607
Fig. 100.
it protruded slightly tbrongh a circular ulcer less than half an inch in
diameter. The substance of the disease presented, to the assisted as
well aa to the unaided sight, and touch, the
well-marked characters of epithelial cancers.
The lymphatic glands were similarly diseased.
A gentleman, 64 years old, had, on the
upper part and right side of his nose, a flat,
lowly lobed or tuberculated growth, an inch in
diameter, gradually rising above the level of
the adjacent sicin to a height of one and a half
or two lines. It was covered with skin, which
was very thin and adherent, and florid with
small dilated bloodvessels, like those in the
akin of his cheek. The base of the growth
rested on the bones ; it felt like an infiltration
of all the thickness of the deeper part of the
aldn and subcutaneous tissues, and moved as
one broad and thick layer of morbid substance
inserted in the skin. In its middle and moat
prominent part was a fissure nearly a line in
depth, with black, dry borders, from which a
very slight discharge issued. It was very
painful, and beginning from no evident cause,
had been ten weeks in regular progress.
I removed this disease, and found in its
centre a small, roundish mass of soft, dark,
gmmous substance, like the contents of a
sebaceous cyst.* Around the cavity in which
this was contained, all the rest of the disease appeared as an outspread
infiltration of firm yellowish and white cancerous substance in the tissues
under the stretched and adherent but entire skin. It extended as deep
as the periosteum of the nasal bones. Soft, crutpbling, and grumous
substance could be scraped from it ; and it yielded well-marked elements
of epithelial cancer, with numerous laminated capsules. During the
healing of the operation wound, a similar ^mall growth appeared in the
ac^acent tissues. It was destroyed with caustic by Mr. Hester, and
the patient has remained well ten years since the operation.
Besides cases such as these, which may sufiice for a general descrip-
tion of the disease, many might be cited of what may be regarded as an
intermediate form, in which both the skin or mucous membrane and the
subjacent tissues are simultaneously affected, but the latter to a much
larger extent than the former. Such cases are far from rare in the
lower lip and tongue. They are characterized by the existence of a
• Mr. Hiilpr and Mr. Rjre, who saw this
pretenied, al flni, atl the cbiracleia of n cor
btlble Ibat it w«* an oiample of epilhelial o
K some weeks before I did, told me lliat ii
3n sebaceou) cyst; and I ihink it quile pro-
II roimrd in and around luch ■ cysl.
608 EPITHELIAL CANCER.
roundish, firm, or hard and elastic lump, deep-set in the part, and well
defined to the touch, with its surface little, if at all, raised, and having
at some part of its surface either a portion of cancerous integument, or
a small ulcer or fissure.
Now these cases of deep-seated epithelial cancers have much interest,
as well in practice as in their bearing on the pathology of the disease.
They are instances of the disease of which it is impossible to speak as
of mere augmentations of the natural structures ; there is in them no
trace at all of the assumed homology of epithelial growths ; there is in
them no progressive formation of epithelial cells gradually penetrating
from the surface into the substance of the cutis ; their progress, or s
part of it, is from the deeper parts towards the surface.
The epithelial cancers in or near the integuments are so prone to
ulceration, that the occasions of seeing them as mere growths are com-
paratively rare. The state in which they are usually shown to us is
that of progressive ulceration of the central and superficial parts, with
more than equal growth of the bordering and deeper parts. In this
state, indeed, they present the type of that which is commonly described
as the cancerous ulcer, a type which is observed, also, in some examples
of the scirrhous cancer (p. 549), and more rarely in the medullary.
In the superficial first-described form of the disease, the ulceration
usually begins either as a diffused excoriation of the surface of the
cancer, the borders of which are alone left entire, or else as a shallow
ulcer extending from some fissure or loss of substance at which the
disease commenced. The discharge from the excoriated or ulcerated
surface usually concretes into a scab, or a thicker dark crust, beneath
which, as well as beyond its edges, ulceration gradually extends in
width and depth.
A nearly similar method is observed, I believe, in the earliest ulcera-
tion of the papillary and other more exuberant epithelial cancers.
The central parts ulcerate first, and the ulcer from this beginning
deepens and widens, destroying more and more of the cancer-structures;
but its rate of destruction is never so quick as that of the increase of
the borders and base of the cancer.
In the deep-seated epitheHal cancers, other methods are observed in
the first ulceration. Sometimes the skin or mucous membrane over
them, becoming adherent and very thin, cracks, as it may when ad-
herent over a scirrhous cancer (p. 548). Such a crack may remain long
with little or no increase, dry and dark, and scarcely discharging ; but
it is usually the beginning of ulceration, which extends into the mass
of the cancer. In other cases, with inflammation of the cancer, its
central parts may soften and perhaps suppurate ; and then its liquid
contents being discharged (sometimes with sloughs), through an ulce-
rated opening, or a long fissure, a central cavity remains, from the
uneven walls of which ulceration may extend in every direction. Antl
again, in other cases, especially, I think, in secondary formations, anJ
ULCERATION. 609
in those under the scan of old injuries, the cancer protrudes through a
sharply bounded ulcer, in the sound integument or scar, and grows
exuberantly, with a soft, shreddy surface, like a medullary cancer, or
with a firmer, warty or fungous mass of granulations.
But though the beginnings of the ulcers be thus, in different instances,
▼arious, yet in their progress they tend to uniformity. The complete
nicer is excavated more or less deeply, and usually of round, or oval,
or elongated shape. Its base and borders are hard, or very firm, be-
cause, as one may see in a section through it, they are formed by can-
cerous substance infiltrated in the tissues bounding it. The thickness
of this infiltration is commonly, in direct proportion to the extent of
the ulcer, from a line to half an inch or more : we may feel it as a dis-
tinct and well-defined indurated boundary of the whole ulcer, hindering
its movement on the deeper tissues. The surface of the base of the
nicer is usually concave, unequal, coarsely granulated, nodular, or
warty: it is florid, or, often, of a dull vermilion, or rusty red color; it
bleeds readily, but not profusely ; and yields a thin ichorous fluid, which
is apt to form scabs, and has a peculiarly strong, offensive odor, some-
thing like that of the most offensive cutaneous exhalations. The bor-
ders of the ulcer, or some parts of them, are, generally, elevated, sinu-
ous, tuberous, or nodulated ; frequently, they are everted and, to a
less extent, undermined. They derive these characters, chiefly, from
the cancerous formations beneath the skin or mucous membrane that
Burrounds the ulcer. These formations may be in a nearly regular
layer, making the border of the ulcer like a smoothly rounded embank-
ment; but oftener, though continuous all around the ulcer, they are
unequal or nodular, and then corresponding nodules or bosses, from a
line to nearly an inch high, may be raised up around the ulcer, or some
part of it. Moreover, these upraised borders may so project as to over-
hang both the base of the ulcer and the adjacent healthy surface of the
skin or mucous membrane ; they thus appear, at once, undermined and
everted. When they are everted, healthy skin is usually reflected
under them, and continued beneath them to their extreme boundary.
When the papillary character of the primary growth was well marked,
the borders of the ulcer often present, instead of the characters just
described, a corresponding papillary or warty structure : for, in these
cases, the cancer continues apt to affect especially the papillae, and
widening areas of them become its seat as it extends. And, even at
the base of the very deep ulcers, the cancerous granulations, though
rising from the tissues far deeper than papillae, may have a similarly
warty construction.
The characters of the ulcer here described, are generally retained,
however deep, and into whatever tissues, the cancer may extend. For
the proper tissues of the successively invaded parts, at first infiltrated
with cancer-structures, seem to be quickly disparted and then removed ;
even the bones rarely produce any outgrowths corresponding with those
610 EPITHBLIAL CANCER.
that are found in medullary cancers ; they become soft, are broken up,
and at length utterly destroyed. Epithelial cancers thus extending pro-
duce the changes described, as characteristic of malignant ulceration,
in p. 346 ; and by similar extension (especially in the affections of the
lymphatic glands), they lay open great bloodvessels more often than
any other ulcers do. I have seen three cases in which the femoral artery
wad thus opened by ulceration extending from the epithelial-cancerous
inguinal glands.
The minute component structures of the epithelial cancers are alike
among all the varieties of construction and external shape that I have
now described ; and, if we omit the proper textures of the part affected,
they may be thus enumerated : (a) epithelial cancer-cells ; (6) nuclei,
either free, or imbedded in blastema ; {c) endogenous or brood-cells ; (d)
laminated epithelial capsules, or epithelial globes. From each of these,
by degeneration or other change, several apparently different forms
may be derived. The proportions, also, in which they are combined
are various in different specimens ; but I believe that diversities of ap-
pearances to the naked eye are not so connected with these proportions,
as with the methods of arrangement, the degrees of degeneration of the
component structures, and the mingling of the products of inflammation
in the cancer.
(a) The most frequent cells (Fig. 101, a), and those which may be
regarded as types, are nucleated, flattened, thin and scale-like. They
are, generally, round or round-oval ; but they seldom have a regular
shape: their outline is, usually, at some part, linear, or angular, or
extended in a process. Their average chief diameter is about yJath of
an inch ; but they range from f i(jth to FT^ffjth, or perhaps beyond these
limits. In the clear, or very palely nebulous, cell-contents, a few
minute granules usually appear, either uniformly scattered, or clus-
tered, as in an areola, around the nucleus.
The nucleus is usually single, central, and very small in comparison
with the cell, rarely measuring more than 55*00 th of an inch in its longest
diameter : it is round or oval, well defined, and subject to no such varie-
ties of shape and size as the cell. It is usually clear and bright, and is
often surrounded by a narrow, clear area ; it may contain two or more
minute granules, but rarely has a bright, distinct nucleolus.
But many of the cells may deviate widely from these characters ; the
most various and (if the term may be used) fantastic shapes may be
found mingled together. The younger cells are generally smaller,
rounder, more regular, less flattened to the scale-like form, clearer, and
with comparatively large nuclei. The older (as I suppose) appear drier
and more filmy ; they are often void of nuclei, and like bits of membrane
in the shape of epithelial scales (b) : they are flimsy, too, so that they
are very often wrinkled or folded and rolled up, so as to look fibrous
(c), and not unlike the elongated epithelium scales so often seen on the
MINUTE STRUCTURES.
611
dorsum of the tongue. Independently of differences of age, some cells
are prolonged in one, two, or more slender or branching processes ;
Pig. 101.*
some are very elongated (as d); some are void of nuclei; some, within
their pale borders, present one or two dimly marked concentric rings,
as if they had laminated walls.
To these varieties may be added such as depend on the progressive
degeneration of the cells. The most frequent (besides the withering,
which, I suppose, is shown in the shrivelled flimsy scales without nuclei
just mentioned) is the change like fatty degeneration in other cancer-
structures. One of the most frequent efforts of such degeneration is
that the place of the nucleus is occupied by a circular or oval group of
minute oily-looking molecules, some bright with black borders, some
dark (Fig. 102). Others, like these, or larger, are generally scattered
Fig. 102.t
through the cell. With the progress of the degeneration, all trace of
the nucleus is lost ; the molecules increase in number and in size, till
the whole cell or scale appears filled with them, or is transformed into
an irregular mass of oily-looking particles, differing in shape alone from
the common granule masses of fatty degenerations.
(6) Nuclei, either free or imbedded in a dimly molecular or granular
basis, are commonly found mingled with the cells. I believe they oc-
cur in the greatest abundance in the most acute cases. They may be
just like the nuclei of the cells ; but, usually, among those that are free,
many are larger than those in the cells ; and these, reaching a diameter
of more than ji/oo^h ^^ ^^ inch, at the same time that they appear
more vesicular and have larger and brighter nucleoli, approximate very
closely to the characters of the nuclei of scirrhous and medullary can-
cer-cells. Indeed, I have seen many nuclei in soot-cancers, which, if
* Yarions epithelial cancer-cells or scales. Magnified 350 times : referred to in the text.
f Celit and ftee nuclei of epithelial cancer, in states of fatty degeneration. Magnified
360 times.
612
EPITHELIAL CANCER.
they had been alone, I could not have distinguished from such as are
described at page 527 : yet all the other structures of these specimens
were those usual in epithelial cancers, and between the different charac-
ters of nuclei there were all possible gradations. The free nuclei, like
the cells, may be found in all stages of degeneration (Fig. 102).
(c) Those which are named brood-cells, or endogenous cells, present
many varieties of appearance, which may be regarded as the results of
one or more nuclei, inclosed within cells, assuming, or tending to as-
sume, the characters of nucleated cells (Fig. 103).* In some cells a
nucleus appears very large, clear, pellucid, spherical : it loses, at the
same time, its sharply defined outline, its boundary becomes shadowed,
and it looks like a hole or vacant space in the cell (a). Thus enlarging,
the nucleus may nearly fill the cell, and appear as a pellucid vesicle.
I think, however, that such nuclei rarely grow to be cysts, like those
whose history is described in Lecture XXII; for cysts containing
serous or other fluids are very rarely found in epithelial cancers.
Neither have I seen instances of free nuclei changed, as those in the
cells are.f
The enlarged nucleus may remain completely pellucid or barren;
but often granular matter appears to fill it ; and, as often, one or two
corpuscles form in it, which now appear as its nuclei, and make it as-
sume the character of a cell, endogenous within the first or parent-cell
(b). The sketches show many of the appearances that may be hence
derived ; and others may be thus explained. When a cell contains two
Fig. 10.34
nuclei, one only of these may enlarge or become inflated (if I may use
such a term for that which fills with liquid, not with air) ; the other
* Wo owe the ability to interpret these appearances, which ilhistrate many things inie-
resting in the general physiology of cells, almost entirely to Virchow (in his Archiv, iiilOT)
and Rokitansky, I. c. Other facts, derived from the examination of solid tumors, and illus-
trating the capacity of the nucleus for development, are in pages 440, 572 : all these may
deserve study in physiology, together with the doctrine of cyst-formation, explained at p.
356, &c. The vesicular spaces which sometimes form not only in cancer-cells, as describe<i
in the text, but in the cells of other parts, as in the thymus, Virchow has described by the
name of physalides (brood-cavities), whilst to the cells in which these spaces arise, he ha«
given the name of physaliphores.
t Virchow, however (Wurzburg Verhandl., i, 100), mentions having found, in a cauli-
flower excrescence of the uterus, alveoli which, after the plan of proliferous cysts, contained
secondary papillary growths. The analogy of other proliferous cysts may indicate that thes?
also originated in nuclei.
X Epithelial cancer-cells, with endogenous development of nuclei, as described in the
text. Magnified 350 times.
HIHUTB STRDCTDRSa.
613
aaj be thett preased against the wall of the cell. Or both nuclei may
alike proceed to the grade of cells, and two cella, flattened at their
place of mataal compression, appear within the parent-cell (c) : or a
secondary nncleiu, t. «., one formed within an enlarged nucleus, may
enlai^ like its predecessor, and become like a pellucid cavity, or may
become a secondary cell, and contain its tertiary nucleus : hence, pos-
sibly, the concentric appearance above-mentioned may be referred to
the series of successively inclosed celUwslle (d). And changes such as
these may equally occur with more than two nuclei : a cell of any grade,
primary, secondary, or later, may be filled with a numerona " brood"
' of nuclei, in which all the above described changes (but not the same
in all) may be repeated.
((f) The laminated capsules, as I have called them (" globes ^pider-
miques" of Lebert), are the most singular and characteristic structures
of the epithelial cancers (Fig. 104). They are not, indeed, peculiar
to this disease ; for I have fonnd exactly corresponding structures in
the contents of an epidermal and sebaceous cyst ; and so has V. Baren-
sprung ;* and I have illustrated a correBpoDding mode of formation in
some of the many-nucleated cells of myeloid tumors (Fig. 73, p. 469).
However, they are, I believe, nowhere so frequent, or so well marked,
aa they are in nearly every epithelial cancer.
Tbeir great size at once attracts the eye : they are visible even to
tbe unaided sight, especially when the softer curdy material of the can-
cer, in which they are generally most abundant, is pressed out on glass.
They appear at first sight like spherical or oval cysts, from jiot^ to
gjgth of an inch in diameter, walled in by irregular fibrous tissue, and
containing granular matter, nuclei, or cells, obscurely seen within them
(Fig. 104, o). They may be clustered together in a muss or a long
Fig. 104. t
cylinder (d); but by breaking them up, or looking more closely, it be-
comes evident that the appearance of fibrous tissue is due to one's seeing
* Tircttow says ibese are common enou){h in
Kiibei them in morbid Ihickpiiingii of culicle undi
ISU. Sm >Im ArcluT, iii, -:>00.
f Fig- 10*- Laminaied epiihelisl cspiule*, deKiil>ed in ihe leil. MagniSed abuui 250
Illations of epirleimis. He de-
, in hid Atcliiv, B. v,H. i, p. 87,
614
EPITHELIAL CANCEB.
the edges of epithelial scales, which, ia successive layers, are irropped
around the central space. Such scales may be broken off, in groups of
two, three, or more, retaining the curved form in which they have lain
(Fig. 104, a). When detached, they generally appear like the dryest
and most filmy of the epithelial scales composing the rest of the cancer
(b) : often they are folded, and look fibrous even when separated ; their
nuclei are shrivelled or not visible ; their contents are often granular.
As they lie superposed, they*appear closely compacted ; bat not on-
frequently granules are distinct in the outer laminar spaces, or on the
inner surface of detached pieces.
The contents filling the central spaces in these laminated capsules
are extremely various; sometimes, or partly, granular and oily parti-
cles diffused in some nebulous material ; more often, or with these, celta
or nuclei (c, d). Sometimes one cell is thus inclosed, sometimes two
or more : and these not scale-like, but oval, or round and plump, baring
distinct and generally large uuclei ; or a crowd of nuclei may be in-
closed : and, briefly, these nuclei may appear in any of those varioog
states which I described just now in the account of the endogenous
epithelial cells. Indeed, it is probable that the last sentence of that
description (p. 613) might begin the history of the development of these
capsules ; for I know no method of explaining them, except that taught
by Rokitansky, and illustrated by the diagrams copied here (Fig. 105).*
In one of the simplest cases, we may suppose a nucleus largely m-
Jlated and filled with a brood of (say four) secondary nuclei, which pro-
ceed to the formation of secondary cells (Fig. 105, a). If, now, only
one of the nuclei of these secondary cells
becomes enlarged, it will not only extend
its own cell's wall into contact with that
of the cell containing it, but will at the
same time press the three other cells inio
similar contact, and thus appear invested
with laminated epithelial scaler. Such a
state, with the nuclei of the investing
scales, is shown in B. A greater com-
plexity of similar events is shown in c, in
which, among a very large number of se-
condary endogenous nuclei, many are per-
sistent as nuclei, while others, developed
to nucleated cells, are laminated around
them. But, among the nuclei, two are
represented as enlarged and containing
tertiary "broods" of nuclei, among which
Fig. 105. t
t Fi«. KJ
esssy, Ueber die Cyste ; Fig. 8.
Diagrams of [he proiliiclion of ihe Inminaled epilhplial capsules
MINUTE STRUCTURES. 615
the same changes have ensued as in the preceding generation. And it
is evident that if anj in the groap a had now singly enlarged, the rest,
with . all the cells and nuclei around them, must have arranged them-
selves or been compressed into imbricated scales, so as to form a large
laminated capsule.
The component structures now described appear to be disorderly
placed in the mass of epithelial cancer, in the interstices of the natural
structures, or of their remains. I have never seen any of them within
a natural structure, e. g, within a muscular fibre. "*" The laminated cap-
sules are, I believe, most abundant in the softer substance, but they
are not confined to it. The texture of the mass is such as makes it
very difficult to obtain a sufficiently thin section with the structures
undisturbed ; but in sections of scrotal cancers I have seen the lami-
nated capsules imbedded at distant intervals among the simpler epithe-
lial structures, and the turgid large capillaries ascending towards the
surface and forming near it simple or undulating loops. The epithelial
structures appear to be in contact with the walls of the bloodvessels,
supported by a wide and scanty meshwork of connective tissue growing
up from the adjacent tissue of the scrotum.
In whatever part or organ they may be found, there is a remarkable
uniformity in the characters of the epithelial cancer-structures. De-
viations, however, from such as I have described as the normal struc-
tures are sometimes met with. I have once seen a melanotic epithelial
cancer : it grew in the deeper part of the cutis and in the subcutaneous
tissue, under a dark pigmentary nsevus or mole, in a woman who had
many similar moles on various parts of her body : a thin layer of the
cutis, with its covering of dark epidermis, extended over the cancer,
and was slightly raised by it. The epithelial shape and texture of the
cancer-cells were well-marked, but most of them contained melanotic
matter ; in some, a quantity of brownish molecular matter was either
diffused or collected about the nucleus or its place ; in some, with simi-
lar molecular matter, there were two, three, or more brown corpuscles,
from the size of mere molecules to that of blood-cells. Materials like
those within the epithelial cells existed, also, more abundantly as an
intercellular substance.
Cells like cylindriform epithelium cells may also be mingled with
the more usual form. I have seen this in a case of large ^' cauliflower-
excrescence" of the uterus, in the very substance of which the cylin-
driform cells were found.
* C. O. Weber in Virchow^s Arcbiv, vol. xv, 1859, has described and figured cases of
epitbelial cancer of the tongue and lip, in which not only in the connective tissue between
the muscular fibres, bat apparently within the fibres themselves, crowds of cells possessing
the epithelial character were situated. These had evidently arisen through division and
prolifemtion of the original cells and nuclei of the textures in which this new cell formation
had taken place.
616 EPITHBLIAL CANCBR IN THB LYMPHATIC QLANDS.
Bidder describes a similar occurrence in a cancer of the stomach*
and duodenum ; and Rokitansky,t in the same parts.|
I believe, also, that cases may be found in which the cancer-cells, or
part of them, have characters intermediate, or transitional, between
those of the epithelial and of the scirrhous or medullary diseases. I
have mentioned the existence of the large free nuclei (p. 611), and the
full plump cells in the capsules (p. 614) in epithelial cancers ; and I
believe that I have seen cancers with all their cells of intermediate
shape. But the point is very difficult to determine. Young epithelial
cells are less flattened and scale-like, and have larger and clearer nu-
clei, than those of completed formation : in these characters they ap-
proach to the appearance of the other cancer-cells ; and if, in a quickly
growing mass, tl^ey occur alone, they may produce a fallacious appear-
ance of an intermediate form of cancer. Moreover, two kinds of can-
cer may be mingled in one mass. Lebert and Hannover have satisfied
themselves of this; and such a specimen as they describe may have de-
ceived me. As yet, therefore, I can have only a belief in the existence
of such intermediate forms.
The foregoing description has been drawn, almost exclusively, from
cases of epithelial cancer in integumental parts, and the varieties which
it may present in different localities are so slight and inconstant, that
such references as I have already made to them may suffice. But cer-
tain examples of the disease, in other than integumental parts, need
separate description.
The Lymphatic Glands, in anatomical relation with the primary
seat of an epithelial cancer, usually become similarly cancerous in the
progress of the disease ; and, I think, sooner or later in that progress,
in direct proportion to its own rapidity, following in this the same rate
as in other cancers. From the glands nearest to the primary seat, the
disease gradually extends towards the trunk, yet seldom reaches far.
I have known the whole line of cervical glands affected in epithelial
cancer of the tongue ; and the lumbar glands may become diseased with
the penis or scrotum ; but, much more often, the proximate cluster of
glands alone becomes cancerous, and those more distant are swollen
and succulent, but contain no cancerous matter. This, however, must
* Mailer's Archiv, 185'2, p. 178.
f Ueber den Zottenkrebs, pp. 11, 18.
J In Path. Transact., vol. viii, p. 254, Mr. J. Hutchinson relates a case of recurrent epi-
thelial carcinoma of the cervix uteri, in which the cells were for the mo?t part columnar in
shape, and many of them possessed ill-formed cilia. In the first growth the cells were tes-
sellated, and of the usual character. Forster also, in his Atlas, pi. 28, fig. 3, recortls a ca«e
of '• cancroid * of the rectum, in which the epithelium cells had the shape of the columnar
or cylindrical epithelium. These cells were large, had finely granular contents, and large
clear nuclei, with nucleoli of a similar character. In many of the cells multiplication by
division was evidently taking place.
SPITHSLIAL CANCER IN THE LYMPHATIC GLANDS. 617
not be taken to imply a continuous extension of the disease from the
primary seat to the glands ; for large intervals of apparently healthy
tissues often intervene. I have seen, with epithelial cancer of the
back of the hand, the lymphatic gland near the bend of the elbow simi-
larly cancerous throughout ; but the whole forearm was healthy. I am-
putated an old man's hand with a similar cancer ; and he died with all
his axillary glands diseased, but with no sign of cancerous lymphatics
or other disease in the arm."*"
In some cases the diseased glands appear in a large cluster, forming
one lobed mass ; in others, a chain of small glands is felt, such as one
might not suppose to be cancerous, except for their hardness. The
cancerous elements in the glands resemble those in the primary disease ;
indeed, I have found even slight modifications of general character in
the one, exactly repeated in the other. f They are inserted among the
natural structures of the gland. At first, I think, they usually appear
in circumscribed masses, occupying only a certain part of the gland ;
but these, gradually increasing, at length exclude, or lead to the re-
moval of, the whole of the original tissues.
The diseased glands are enlarged, hardened, smooth-surfaced, and
usually retain their natural connection with the surrounding tissues.
On section, part or the whole of the gland presents the same appear-
ance as a section of primary epithelial cancer; and, generally, the
opaque-white crumbling substance, like scrapings from macerated epi-
dermis, is abundant. One can remove masses of it, and leave only the
capsule of the gland, or some remains of gland-substance that bounded
the spaces that it filled.
Glands thus diseased are not unfrequently the seats of acute inflam-
mation, in which, with fatty degeneration of the cancer-cells, suppura-
tion may ensue : they may discharge the pus, as from a common bubo,
and may continue many days thus suppurating. But the end of this
is, that large and deep cancerous ulcers, such as are already described,
form in them and the adjacent tissues, and the progress of these is often
more serious than that of the primary disease.
I have seen two examples of primary epithelial cancer in lymphatic
* Such oases do not prove— they only make it very probable — that there was no can-
cerous aflfection of the lymphatic vessels between the primary disease and the glands.
Such continuous disease has been traced from scirrhous cancers of the breast to the axillary
glands ; and I once found epithelial cancer-cells in the dental canal, when primary disease
existed in the gum and alveolar part of the jaw, and secondary disease in a submaxillary
lymphatic gland.
f In one case of epithelial cancer of the tongue, and in another of the larynx, I found the
lymphatic glands affected with what, according to both general and microscopic characters,
ooald only be regarded as firm medullary cancer. It is possible that, in these cases, the pri-
mary disease was of mixed kinds, — ^medullary and epithelial : just as there are examples of
mixed cartilaginous and medullary tumors, in which only the medullary disease is repeated
in the lymphatic glands (see p. 459). But I found no evidence of this mixture of diseases
in the primary growth ; and I think it equally possible that the cases may be compared
with the rare instances of secondary medullaty, associated with primary scirrhous, cancer.
40
618 EPITHELIAL CANCER OF THE LUKGS.
glands ; one I will relate, both for its own interest, and because it illus-
trated many of the foregoing statements. The man, who was a patient
in St. Bartholomew's Hospital, was a sweep, 48 years old : his skin
was dusky and dry, and many hair-follicles were enlarged by their ao-
camulated contents ; but he had no appearance of cancer, or wart of
any kind, on the scrotum or penis : yet his inguinal glands were dis-
eased just as they commonly are in the later stages of scrotal soot-can-
cer. On the right side, over the saphenous opening, a cluster of glands
formed a round tuberous mass, more than an inch in diameter. It felt
very firm, heavy, ill-defined, and as if deep-set. Over its most promi-
nent.part the skin was adherent, and ulcerated, and a soft dark growth
protruded through it. Above this mass were three glands enlarged,
but not hardened. On the left side, below the crural arch, one gland
was enlarged to a diameter of half an inch, and hard ; and four others
felt similarly but less diseased. All these were movable under the skin.
This disease had been observed in progress for fifteen weeks, having
begun in the right groin as a hard lump under the skin, like those which
were now in the left groin, and which had commenced to enlarge some-
what later. The ulceration in the right groin had existed for a week.
I removed all the glands that seemed diseased. The chief mass, fnmi
the right side, appeared, on section, lobed, soft, grayish, mottled with
pink and livid tints. The same changes, but with increased firmness,
were seen in the largest gland from the left side ; and the material
pressed from both these (a turbid, grumous, and not creamy, substance)
contained abundant epithelial cancer-cells. The other glands were not
evidently cancerous ; but, during the healing of the operation on the
right side, a gland, which I had thought it unnecessary to remove,
enlarged and became hard : it was destroyed with chloride of zinc, and
then the wounds healed soundly. The patient remained well for st
least six years.
The Epithelial Cancer of the Lungs, which I referred to (p. 596) m
having once seen, occurred in an old man whose penis was amputated
eighteen months before death. The disease soon returned in the ingui-
nal glands, and I received these and the lungs for examination. The
other organs were reported healthy.
A cluster of three or four glands was compressed in a large mass, of
which a part protruded through an ulcerated opening in the skin. On
section, nearly the whole of the gland-substance appeared replaced by
the peculiar and oft-mentioned whitish, half-dry, friable substance, with
grayish mottlings and streaked with bloodvessels. In this substance all
the structures of epithelial cancer, with abundant laminated capsulefl,
were perfectly distinct ; they might have been taken as types.
In the lungs there were about twenty masses of similar cancerous
substance ; and of one large mass, at the root of the right lung, I could
not be sure whether it were in the lung itself or in a cluster of bronchial
EPITHELIAL CANCER OP THE UTERUS AND VAGINA. 619
glands. They were nearly all spherical, or flattened under and in the
pleura, and measured from ^ of an inch to nearly 3 inches in diameter.
Their substance was opaque-white, marbled with pale yellow and pink,
intersected by lines of gray and black (belonging apparently to the in-
terlobular tissue of the lungs), and marked with bloodvessels. They
were compact, but brittle and crumbling under pressure : several of the
largest were softer and more friable at their centres than elsewhere,
and the largest three had great central cavities, filled with softened
cancerous matter and pus: they might have been called ^'cancerous
vomicae;" but they were completely bounded by layers of cancer, rough
and knotted on their inner surfaces, and had no communication with air-
tubes. From one mass an outgrowth projected into, and had grown
within, a bronchial tube ; from another a similar growth extended into
a pulmonary artery.
The crumbling, brittle texture of these masses, and the absence of
creamy "juice" in even the softest parts, might have sufficed, I believe,
to declare that these were not masses of scirrhous or medullary cancer :
but the microscopic examination left no doubt. Their minute structures
accorded exactly with those in the inguinal glands : not a character of
the epithelial cancers was wanting. "*"
Epithelial Cancer in the Heart is illustrated in the Museum of St.
Bartholomew'8.t A man, 58 years old, had a granulated and warty
epithelial cancer, which covered the anterior and inferior third of his
eye, and was firmly combined with the conjunctiva and parts of the
sclerotica and cornea. Mr. Wormald removed the eyeball with all the
disease. Two years afterwards, the man died with a large tumor over
the parotid gland ; and a mass of cancer, about an inch and a half in
diameter, was imbedded in the substance of the apex of the right ventricle
and septum of the heart. The mass is soft and broken at its centre,
and has the microscopic structures of epithelial cancer.
In the Uterus, and the adjacent part of the Vagina, the epithelial
cancer may be found with ordinary characters, such as were described
at the beginning of the lecture ; but its more remarkable appearance is
in the form of the *' Cauliflower-Excrescence." Only a part, however,
of the cases to which this name has been ascribed have been epithelial
cancers : of the rest some were medullary cancers, and some, perhaps,
simple, non- cancerous, warty, or papillary growths.
My own observations of this disease have only sufficed to confirm
(wherever I could test them) those far more completely made by Vir-
* Portions of the lungs and of the inguinal glands, in this and in the last-described case,
•re in the Museum of St. BertbolomewV
f Series xii, 60. In tbe Catalogue the disease is described as medullary cancer; but I
have recently examined microscopically both it and the primary growth (Series iz, No. 17);
and they are certainly epithelial cancers.
620 CAULIPLOWER-BXCRBSCBNCB.
chow,* whose results, approved by Lebert, and consistent with the best
earlier records, I shall therefore quote : ^^ One must distinguish three
different papillary tumors at the os uteri, — the simple, such as Frerichsf
and Lebert J have seen ; the cancroid; and the cancerous" — [t. e. the
epithelial-cancerous and the medullary-cancerous] : the first two forms
together constitute the cauliflower-growth. This begins as a simple
papillary tumor, and at a later period passes into cancroid [epithelial
cancer]. At first one sees only on the surface papillary or villous
growths, which consist of very thick layers of peripheral flat, and in-
terior cylindrical, epithelial cells, and a very fine interior cylinder
formed of an extremely little connective tissue with large vessels. The
outer layer contains cells of all sizes and stages of development ; some
of them forming great parent-structures with endogenous corpuscles.
The vessels are, for the most part, colossal, very thin-walled capillaries,
which form either simple loops at the apices of the villi, between the
epithelial layers, or towards the surface develop new loops in constantly
increasing number, or, lastly, present a reticulate branching. At the
beginning of the disease the villi are simple and close pressed, so that
the surface appears only granulated, as Clarke describes it : it becomes
cauliflower-like by the branching of the papillae, which at last grow out
to fringes an inch long, and may present almost the appearance of an
hydatid-mole.
^' After the process has existed for some time on the surface, the can-
croid alveoli begin to form deep between the layers of the muscular and
the connective tissues of the organ. In the early cases I saw only
cavities simply filled with epithelial structures ; but in Kiwisch's case
there were alveoli, on whose walls new, papillary, branching growths
were seated, — a kind of proliferous arborescent formation."
It will be evident, from this description, that the cauliflower-excres-
cence, in the two conditions distinguished by Virchow, illustrates the
usual history of the most exuberant epithelial cancers (p. 599) : it might
be taken as the principal example of the group. That which he calls
the *' simple papillary tumor" is an excessive papillary outgrowth of
epithelial cancer ; the later stage of the same, when it " passes into
cancroid," is the usual extension of such a cancer into deeper parts, —
a continuous growth of the same thing in a new direction. For the
papillary structures, composed, as Virchow says, of epithelial cells with
bloodvessels and a very little connective tissue, are the essential cha-
racters of the epithelial cancerous outgrowths ; and I believe that the
same composition has never been seen in any papillary or warty growths,
that did not, if time were allowed, proceed to the formation of epithelial
structures in the deeper parts, and thence through the usual progress
of malignant disease.
* WQrzburg Verhandl., 1850, B. i, 109. They were chiefly made in the eases deacribed
by Mayer in the Verhandl. der GeseUsch. fllr GeburtahQlfe in Berlin, 1851, p. 111.
t Jenaische Annalen, p. 7. J Abhandlungen, pp. 67, 150.
RODBNT ULCERS. 621
Before entering on the pathology of epithelial cancers it will be useful
to refer briefly to the morbid anatomy of the diseases with which they
have most affinity, and from which it is most necessary to distinguish
them, — at least, as clearly as we can. These are, on the one side, the
scirrhous and medullary cancers ; and, on the other, certain rodent
nlcers and warty growths of scars.*
The descriptions in former lectures of the scirrhous and medullary
cancers of the skin and subcutaneous tissue may suffice for the distinc-
tion from them (compare pp. 538, 535, 579).
The Rodent Ulcer is the disease which has been described under
▼ariouB names : such as cancerous ulcer of the face, cancroid ulcer,
nlcdre rongeant, ulcere chancreux dn visage, der flache Erebs, moosar-
tige Parasit, ulcus exedens, noli me tangere. In its earliest appear-
ance, on its most frequent seat, it has been called cancerous tubercle of
the face. It has been confounded by many with different forms of
cancer ; yet it is distinct from them in structure as well as in history,
and had better be described by some name which may not add to the
yearly increasing confusion that arises from the use of terms expressing
likeness to cancer.
dir B. G. Brodie thus describes the most frequent characters of the
disease if *^ A man has a soft tubercle upon the face, covered by a
smooth skin. He may call it a wart, but it is quite a different thing.
On cutting into it you find it consists of a brown solid substance, not
▼ery highly organized. A tumor of this kind may remain on the face
unaltered for years, and then, when the patient gets old, it may begin
to ulcerate. The ulcer spreads slowly but constantly, and, if it be left
alone, it may destroy the whole of the cheek, the bones of the face, and
ultimately the patient's life ; but it may take some years to run this
course. So far these tumors in the face, and these ulcers, are to be
considered as malignant. Nevertheless, they are not like fungus hae-
matodes or cancer; and for this reason, that the disease is entirely
local. It does not affect the lymphatic glands, nor do similar tumors
appear in other parts of the body."
The constantly progressive ulceration is a character in which this
disease resembles cancer, especially epithelial cancer. The likeness in
this respect may indicate some important affinity between them, but the
differences between them are greater ; for not only is the rodent ulcer
usually unlike that of any cancer in its aspect, rate, and mode of pro-
gress, but the tissues bounding it, and forming its base and walls, never
* The whole of this subject is admirably illustrated by Mr. Cssar Hawkins, in papers
in the Medico-Chir. Trans., vols, xix and xxi, and in the Medical Gazette, vols, xxviii, xxix.
Indeed, I can add nothing to his account, except such conclusions as are derived from mi-
croscopic examinations of the diseases. One of Mr. Hawkins' lectures relates to cheloid
growths ; but to these it seems unnecessary to refer ; if they could be confounded with any
form of cancer, it would be with scirrhous cancer of the skin.
f In hit Lectures on Pathology and Surgery, p. 333.
622 RODENT ULCERS.
contain any epithelial or other cancerous structure ; they are infiltrated
with only such structures as may be found in the walls of common chronic
ulcers.
The most usual characters of the rodent ulcer, whether on the cheek,
the eyelids, upper lip, nose, scalp, vulva, or any other part, are as fol-
lows:* It is of irregular shape, but generally tends towards oval or cir-
cular. The base, however deeply and unequally excavated, is usually,
in most parts, not warty or nodular, or even plainly granulated ; in
contrast with cancerous ulcers, one may especially observe this absence,
or less amount, of up-growth. It is, also, comparatively dry and glossy,
yielding, for its extent, very little ichor or other discharge, and has
commonly a dull reddish-yellow tint. Its border is slightly, if at all,
elevated; if elevated, it is not commonly or much either everted or
undermined, but is smoothly rounded or lowly tuberculated. The im-
mediately adjacent skin usually appears quite healthy.' The base and
border alike feel tough and hard, as if bounded by a layer of indurated
tissue about a line in thickness. This layer does not much increase in
thickness as the ulcer extends ; and herein is another chief contrast
with cancerous ulceration : in the progress of the rodent ulcer we see
mere destruction ; in the cancerous we see destruction with coincident,
and usually more than commensurate, growth. It is only in the rarest
cases that a growth is associated with rodent ulcer. In one such case,
a gentleman about 55 years old had, for nine years, a well-marked ro-
dent ulcer of the ear, which was several times partially healed. At
length, a firm spheroidal growth, nearly an inch in diameter, appeared
in the subcutaneous tissue at the border of the ulcer. I cut off the
upper half of the ear with the adjacent growth, expecting to find that
it was an epithelial cancer ; but it had no cancer structures ; only such
corpuscles as I have always found in the borders and bases of the rodent
ulcers.
This indurated substance at the base and borders of the ulcer appears,
on section, very firm, pale grayish, uniform or obscurely fibrous ; little
fluid of any kind can be pressed from it. It is composed of the same
elementary structures as common granulations are, and these, in the
deeper layers, are inserted among the tissues on which the ulcer rests.
I have examined very carefully six of these ulcers, removed by excision,
and have never seen in or near them a structure resembling those of
epithelial or any other form of cancer. Leber t*s observations, I believe,
fully coincide with mine ; though he classes the disease with epithelial
cancers, under the general name of Cancroid. Mr. Jonathan Hutchin-
son, also, has made several examinations of pieces cut, during life, from
* The parts enumerated were the seats of disease in the cases from which 1 have drawn
my description, and in which it is, I believe, most frequent ; but it is not confined to them.
Lebert refers to cases of it, in his account of the cancroid of the uterus, and sugge5ts (what
is highly probable) that the simple chronic, or perforating, ulcer of the stomach is a disease
of the same nature.
CANCER OF SCARS. 623
the margins of rodent ulcers, and always with the same result : thej
noTer contained structures resembling those of epithelial or any other
cancer.
Thus the anatomical distinction between this disease and cancer is
evident, and they are equally different in pathology ; the rodent ulcer,
80 far as it has been observed, is never attended by similar disease in
the lymphatics or any other part ; and if completely removed or de-
stroyed, it does not recur.
The Warty Orowths on Scars (Cancers of Cicatrices) are usually
well-marked papillary epithelial cancers, which grow in the place of
scars remaining after injuries or common ulcers. Mr. Hawkins,"^ who
has given a very full account of their general characters and progress,
describes cases in the scars of bums, gunshot-wounds, floggings, and
ulcers. All that I have seen were on the lower extremities, and con-
nected with scars after repeated injuries, f
The description already given of the warty epithelial cancers may
suffice for these. They usually exemplify very well the widespread
growth and cancerous change in the papillae ; the enlargement, at first
probably simple, and afterwards with cancerous formation, in the pa-
pillae of the adjacent skin ; the deep extension of the disease to the peri-
osteum, and thence onwards, even to the complete penetration of the
bones and other subjacent tissues ; and, at a late period, the cancerous
disease of the lymphatic glands. But it is important to be aware
that this di9ease may be closely imitated by warty growths and ulcers,
in and about which no cancerous matter can be found. I examined very
carefully such an ulcer with prominent growths on the front of a man's
leg. It was seated in the middle third of the leg, in the place of a
large old scar after a scald, and the greater part of the ulcer presented
high, lobed and nodulated, hard granulations. No one doubted, before
the amputation, that the disease was the usual form of cancer ensuing
in these conditions ; yet no cancerous structure could be found ; in
whichever part* I examined, I could find only inflammatory products,
and such corpuscles as compose ill-developed or degenerate granulations
upon common ulcers. Similar warty diseases, very closely resembling,
to the naked eye, the epithelial cancers, and often, like them, ulcerat-
ing, are not very rare on the lower lip ; and I have seen them on the
tongue.|
I think some of the diversities of opinion respecting the nature of
these warty growths and ulcers may be due to the want of distinction
between those which are, and those which are not, epithelial cancers.
* Medical Gazette, vol. zzviii, 872 ; and Med.-Chir. Trans., xix. See, also, the Dublin
QvMrterljr Journal, 1850-51.
f Thejr are aniply illustrated in the Museum of St. Bartholomew's, Ser. i, and Ser. xxxv.
40. Several cases are described by Mr. Stanley (Treatise on Diseases of the Bones, p. 300).
X The growths described by some of the German pathologists, by the name of destructive
papillary tumor of the skin, are doubtless the same as these ulcerating warty growths.
624 EPITHBLIAL CAKOBR — INFLUBVCB OF SBZ.
Certainly, the opinion that epithelial cancer is thoroughly curable by
operation, and is altogether a much less malignant disease than the
other varieties of cancer, is due, in great part, to warty growths and
ulcers having been considered cancerous, which were not so. To the
naked eye and during life, the two diseases may be very much alike;
but the difference in their respective minute structures b clear, and in-
dicates essential difference of nature : certainly, in the pathology of
epithelial cancer, caution is necessary in reckoning any of these cases
that have not been microscopically examined.
I would add, that I have no doubt that the epithelial growth, in some
cases, proceeds from the periosteum or other subcutaneous tissues, and
thence extends into and through the skin. I have seen the growth pro*
truding through an ulcerated aperture in the scar, just as any deep-
seated tumor might. Such cases justify Mr. Stanley's description of
the disease as one, primarily, of the periosteum.
LECTURE XXXII.
EPITHELIAL CAKGEB.
PART 11. — PATHOLOGT.
Among all the caDcers, the epithelial present the general or constitu-
tional features of malignant disease in the least intense form. They
commence at the latest average period of life ; they appear to be most
dependent upon local conditions ; they are least prone to multiplication
in internal organs ; they are associated with the least evident diathesis
or cachexia. And yet I believe that in a large survey of them, none
of the features of malignant disease, as exemplified in the scirrhous and
medullary cancers, will be found wanting : the difference is one of degree,
not of kind.
(a) A large majority of the cases of epithelial cancers occur in males.
In 105 cases, affecting parts common to both sexes, 86 were in men,
and 19 in women. In the cases affecting the sexual organs themselves,
I think the proportion is nearly equal ; unless we reckon the scrotil
soot-cancers, which, for obvious reasons, we should more properly ex-
clude.
(b) A few cases are on record, transmitted from book to book, in
which what were probably epithelial cancers occurred before adult life.
Sir James Earle saw a scrotal soot-cancer in a child eight years old f
* Pott's Works by Earle, iii, p. 178.
EPITHELIAL CANCER — INFLUENCE OF AGE. 625
80 did Mr. Wadd;* and M. Lebertf examined a '^cancroid" growth at
the vnlva in a child 8| years old, in whom it was almost congenital.
But cases such as these cannot be taken into oar estimate of the influ-
ence of age in determining the access of the disease. In the following
table, I have included no cases that were recorded merely or chiefly on
accoimt of the patients* ages :%
Age. No. of Omm.
20 to 30 9
30 « 40 22
40 " 50 40
50 « 60 32
60 " 70 30
70 « 80 10
143
If now, as in the last two lectures (pages 543, 582), we calculate,
from this table, the frequency of epithelial cancer in proportion to the
number of persons living at each of the successive periods, it may be
represented by the following numbers (100 being, as before, taken to
express the frequency between 40 and 50) :
20 to 30 years, 12
30 " 40 " 41
40 « 50 " 100
50 « 60 " 119
60 « 70 »* 163
70 " 80 " Ill
We may probably deduce from this calculation, which is confirmed
by Mr. Baker's tables,§ that the conditions favorable to the production
of epithelial cancers regularly increase with the increase of age ; for
the apparent diminution after 70 may be reasonably ascribed to the
comparatively small proportion of persons beyond that age who are re-
ceived into hospitals, or who are under such surgical treatment as to
have their cases recorded.
The proportions expressed by the foregoing general tables are nearly
true for the epithelial cancers of each part most liable to be affected :
the only notable peculiarities, I believe, are, that the mean age of its
* Curling on the Diseases of the Testis, iii, p. 5*28.
f Trait^ Pratique, p. 676. Hannover (Das Epithelioma, p. 104) quotes from Frerichs a
case in which the disease extended from the ear through the petrous bone in a male 19
years old.
t The table includes cases from Lebert, Hannover, and others. But I have omitted, both
I
from it, and from the preceding one, Lebert's cases of " cancroid" of the face. They were
examples of rodent ulcers, and their contrast with epithelial cancers (of the lip, for ex-
ample) is well shown, in that the average age for their coming under operation is 17 years
later, and the proportionate frequencies in the two sexes is reversed. The ages assigned in
the above table are, with few exceptions, those at which the disease was first observed by
UupatUnti.
2 Med.-Chir. Trans., vol. xlv.
626 BPITHBLIAL CANOBR.
occurrence is lowest in the sexual organs, and highest in the integu-
ments of the head, face, eyelids, and upper extremities.
(c) An hereditary disposition to soot-cancer has been seTerml times
obserTed: as by Mr. Earle,* in a grandfather, father, and two sons; by
Mr. HawkinB,t in a father and son ; by Mr. Cusack,^ in a mother ti^
son ; by myself (twice) in two brothers. But all the persona here re-
ferred to were engaged in the same trade, and their exposure to the
same exciting or predisposing cause of the disease diminishes the yalue
of the facts as indications of hereditary predisposition. I have no cer-
tain record of other epithelial cancers occurring in many members of
the same family ; but among 66 patients with epithelial cancer, 10 were
members of families in which other members have had scirrhous or me-
dullary cancers, and two were sweeps, whose brothers had similar soot-
cancers.
Among 160 instances of cancer, in most of which the point was in-
quired into, though none were collected for the sake of it, these cases
were found : (1) A man had medullary cancer of a toe : his father had
cancer of the lip. (2) A woman had repeated epithelial cancers of the
labia; her sister, her father's sister, and her mother's brother's
daughter, had cancer of the breast. (3) A man had epithelial cancer
of the lip, whose grandmother had cancer of the breast. (4) A gentle-
man had epithelial cancer of the interior of the cheek : his aunt died
with cancer of the breast. (5) A woman had medullary cancer of the
breast : her mother had cancer of the uterus, and her uncle cancer of
the face. (6) A woman had scirrhous cancer of the breast, whose
mother's uncle had cancer of the lip. (7) Of another woman with
similar cancer, one cousin had cancer of the lip, another cousin cancer
of the uterus. (8) A third woman had scirrhous cancer of the breast,
whose grandfather had cancer of the lip.§
The proportion of these cases (only j'oth of the whole number) may
seem too small to be even suggestive ; yet it is too large to be referred
to chance. Let it be contrasted with these facts : (1) I have found that
among 116 patients|| with cancer, only one was aware of any member
of the same family having had a simple tumor. This was a woman
with scirrhous cancer of the breast, from whose sister a myeloid tumor
* Med.-Chir. Tran?., xii, SOn. f Medical Gazette, xxi, 842.
X Quoted by Mr. Curling (On Diseases of the Testis, p. 528).
2 Dr. Warren mentions this: A grandfather died with a cancer of the h'p. His sod and
two daughters died with cancer of the breast. One of his grandsons and one of his graiMi*
daughters had also cancer of the breast (On Tumors, p. 281). It may be Directed by some,
that the cancers of the lip here referred to were not epithelial. I assume that they weie^
because of the exceeding rarity of any other kind in the lip : indeed, I have not yet sen
one, or a complete record of one, in which the microscope did not find the epithelial
structures.
0 These were part of the 100 mentioned above ; but I have here reckoned only the oases
recorded by myself, because it is probable that, even if, among the others, any instancei
had occurred of innocent and malignant tumors in the same family, they would not bate
been mentioned.
INFLUENCE OF INJURT AND PREVIOUS DISEASE. 627
of the breast had been removed. (2) Among 77 patients with non-
cancerous tumors, 10 were aware of near relations having had similar
diseases : bat among the same 77, the only cases of family connection
with cancers were the following : (a) The cases of recurring and dis-
orderly-growing mammary tumor related at p. 491 ; (b) the case of
anomalous cartilaginous tumors at p. 446 ; {c) that of the same woman
whose case was just mentioned as one of myeloid tumor of the breast :
five years after its removal, she and her sister were at the same time in
St. Bartholomew's with scirrhous breasts ; (d) that of a lad with mixed
cartilaginous and glandular tumor over his parotid gland, whose grand-
mother had cancer of the breast. Now of these cases the first two must
be regarded, I believe, as instances of a cancerous disposition, modified
and gradually ceasing in its transmission from parent to offspring (see p.
491, &c.) ; the third is a very anomalous one, exemplifying the forma-
tion of a most rare tumor in the breast, not long before it became can-
cerous ; the fourth alone is an instance of an ordinary simple or inno-
cent tumor growing in one who had a cancerous relation.
I have referred to these cases, not to suggest that when cancer has
occurred in one or more members of a family, the rest are peculiarly
unlikely to have innocent tumors, but to show, by contrast, that the
proportion of cases in which epithelial and other cancers occur in the
siune family is, relatively, considerable. For if that proportion were
the result of chance coincidences or errors in observation, an equal or
nearly equal proportion of coincidences should have appeared in the
opposite set of cases. But the contrast between the two sets of cases
is remarkable ; and I believe the facts may be justly regarded as evi-
dence for the close affinity between epithelial and other cancers, and as
an illustration of the modification which the cancerous and other dia-
theses may undergo in their hereditary transmission.
(d) Among 34 patients with epithelial cancers, 19 were aware of in-
jury or previous morbid condition in the affected part, — a much larger
proportion than is found among patients laboring under tumors of any
other kind, except melanoid cancers of the skin.
In certain cases, injury by violence appears as the exciting cause.
But the histories of epithelial cancers differ from those of others in that
the kind of injury which is most effective in their production is such as
is often inflicted, — ^frequent blows or slight wounds on the same part ;
hurts of scars and other seats of old injury. It is as if it were neces-
sary that the part should be considerably changed in structure before
it is appropriate for a cancerous growth.
^ It agrees with this that, in the majority of cases, patients assign as
the cause of the disease, not injury, or not it alone, but some former dis-
ease, especially such as arises from long-continued irritation of a part.
Thus epithelial cancers arise sometimes in old ulcers, as on the legs,
or, as I have known, in perineal urinary fistulse ; sometimes, in those
of more rapid progress, as I once saw in a case of necrosis of the hard
628 BPITHELIAL CAKCBR.
palate, and once in a case of necrosis of the angle of the lower jaw, and
as Frerichs describes, in an ulceration of the internal ear, following
scarlet fever. The majority of the epithelial cancers of the prepuce
and glans occur in those who are the subjects of iX)ngenital phymoeis,
and in whom we may assume the frequent irritation of the part by de»
composed secretions. In some rare cases, a mole or pigmentary neTos
becomes the seat of the disease. But, among all the things referred to
by patients, none are so frequently named as ^^ warts."*
The affections thus named are not usually such as are commonly
called warts. They are not usually like the warts (Yermcse, or Condy*
lomata elevata) that grow on the genital organs during gonorrhosal or
other similar irritation ; nor like such warts (Yerrucss vulgares) as are
common on the hands of young people before puberty ; nor Uke the
condylomata (C. lata) of syphilis. Such papillary growths as these
may, I believe, precede epithelial cancer; but I think they rarely do so.
The general condition of the ^' wart" is, I think, that a small portion
of the cutis is slightly indurated ; its papillss are, generally, in some
measure enlarged ; and it is covered with a darkish dry crust, or with a
scab, or, if the part be very moist, with a soft layer of detached scales.!
The induration of the cutis, and the predominance of the crust or other
covering (which apparently constitutes more of the disease than either
the induration or the papillae) mark the chief differences between this
disease and any of the ^* warts '* just referred to. The induration which
patients often describe as ^' a little hard knot," is usually attended with
elevation, but sometimes with contraction and depression of the piece
of cutis. The crust consists, for the most part, of epidermal scales held
together by dried secretion, or, in its deepest layers, forming whitish
friable substance and fitting between the papillae. It is easily detached
and quickly removed; and, when it is removed, the subjacent cutis
does not usually appear raw or bleeding, but is tender, florid, and as if
covered with a very thin glossy layer of epidermis. When a moister
yellow scab covers the induration, the surface beneath it is usually more
inflamed and excoriated, and the papillae are more enlarged.
Such incrusted warts as these are very common, especially on the
faces of old persons : the large majority of them lead to no further
trouble ;| yet some become the seats of epithelial cancers, and some of
rodent ulcers. A similar affection often precedes the epithelial cancer
of the lower lip. Some slight violence often applied, such as that of a
* It is implied here that the form of cancer assumed in or by warts, is always the epi-
thelial. Some cases by Mr. Butcher (Dublin Quarty. J. of Med. So., Nov., 1856) appear
to be instances of medullary cancer originating in warts.
f Such as these are well described by Schuh (Pseudoplasmen, p. 46), under the title
"barky warts." With the same intimation of likeness, Dr. Warren (On Tumors, p. 27)
called the disease " Lepoides. ''
{ Virchow (in his Archiv, B. vi, H. iii, p. 553) says that the small hairy knots, which are
so frequent on the faces of old persons, have exactly the structure of the cutaneous cavemoas
tumors. But these, I think, are not peculiarly apt to be seats of epithelial cancer.
INFLUENCE OF INJURT AND PREVIOUS DISEASE. 629
short pipe habitually supported by the lip, or the frequent slight rend-
ing of the surface of a dry scaly lip, or one much exposed to the weather,
leads to a ^* little crack :" this scabs over, and after repeated removals
and renewals of the scab, there is a ^Mittle hard lump" or ''a sort of
wart," with a head or crust. And such a wart might be as often in-
nocuous on the lip as on the face, if it were not that the lip is in the
unhappy singularity of being within easy reach, at once, of the fingers,
the teeth, the tongue, and the other lip ; so that when it is as yet but
slightly diseased, it is never left at rest.
A similar drily scaled or incrusted warty change of the cutis often,
I believe, precedes the chimney-sweep's cancer ; and I suspect that the
true influence of the soot in this disease is not that its continued contact
determines the growth of cancers, but (at least in part) that it produces
a state of skin which provides an apt locality for epithelial cancer in
persons of cancerous diathesis. How it does this I cannot imagine :
but this is only one of many things unexplained in this strange dis-
ease; for the whole of the peculiarities of the chimney-sweep's cancer —
its dependence on soot, while coal-dust is wholly inoperative (for the
disease is unknown among colliers) ; its comparative frequency in Eng-
land, especially in the large towns, while in other countries where soot
is abundant it is hardly seen ; its selection of the scrotum for its most
frequent seat, — all these, and many like facts in its history, appear
completely inexplicable. Still, it is certain that scaly or incrusted
small warts, such as I have been describing, are very common in chim-
ney-sweeps. In many of them, even when they are thoroughly cleaned,
the whole skin is dry, harsh, and dusky ; and, before operation for the
removal of scrotal cancers in them, it is a common question whether
one or more warts or scaly patches near the chief disease should be re-
moved with it. Nor are such warts confined to the scrotum ; they may
exist on every part of the trunk and limbs ; and I have seen sweeps so
thickset with them, that a hundred or more might have been counted.
Such are some of the numerous morbid states, one or other of which
may, in the majority of cases, be assigned as predisposing a part to be-
come the seat of epithelial cancer. Expressions are sometimes used,
implying that the part does not become the seat of a new morbid struc-
ture, but that its mode of action is changed, or that the change is only
due to the extension and deepening of a common epidermoid or warty
growth. The truer view, however, may be expressed by saying that
the part, whatever were its previous state, becomes the seat of epithe-
lial cancer, the structures of which, as of a new disease, are inserted
among the original or previously morbid textures of the part. This
evidently happens when the cancer appears in parts previously healthy,
or in the deep-seated tissues, or in the walls of ulcers, or in a pigmen-
tary nssvns; for, in these cases, no morbid structures like those of the
epithelial cancer existed previous to its access. There is more appear-
ance of similarity and continuity of disease between the epithelial can-
630 EPITHELIAL CANCER.
cers and the warty growths by which they are sometimes preceded; for
here both the earlier and the later disease may have, in common, an
accumulation of epidermoid cells and an enlargement of papillae. Yet
the warts, whether incrusted, or others, in which the epidermoid struc-
tures are only superficial, should also, I think, be regarded as only pre-
disposing conditions of epithelial cancer ; as diseased parts, not cancer-
ous, though peculiarly apt to become the seats of this form of cancer.
For the great majority of these are stationary affections, or may disap-
pear, or be cured, even in cancerous persons ; they are comparatively
few in which, after a certain duration as simple warts, the cancerous
disease is manifested. And the time of this change in them is often
well marked. Nearly all patients — even those who can assign no date
to the beginning of the wart or hardness, or other previous disease, —
can refer exactly to some time of change in it, when it began to " grow
up," or "be sore," or "get bad," discharge, or bleed. They thus mark
the time when the cancerous mode of progress was commenced ; and
from this time the history of all such cases is nearly uniform— even re-
markably uniform, if it be compared with the variety of the histories of
the previous states.
Now, I believe that this change in the life of the warty or other diseased
part is always associated with a change in its structure; and that what-
ever were its previous state, its proper tissue, whether papillae or any
others, now become the seat of the formation of epithelial cancer-cells.
It is hardly possible to prove such a change of structure in any single
case, but it is rendered highly probable by this, — that in those warty
structures which we remove because experience makes us believe that
they are in progress as epithelial cancers, we find the tissues infiltrated
with the specific cancer-cells ; while in those which have been long sta-
tionary, without extension or outgrowth, without ulceration or ichorous
discharge, no such infiltration is found. Certain cases must be ex-
cepted from this statement because of error in diagnosis. I have
known rodent ulcers excised, in the belief that they were epithelial
cancers ; but I never saw any growth removed as an epithelial cancer,
in which the epidermoidal cells were placed only on the surface of the
vascular tissues ; and, on the other hand, I have never seen such cells
in the cutis or papillae of any incrusted or other wart, in which the
cancerous mode of progress was not yet manifested. The opportunities
of examining such warts as observation shows to be most apt to be
precursors of epithelial cancer are rare ; but I have examined some on
the scrotum, and one on a lower lip. The last may deserve descrip-
tion.
A healthy-looking farmer, 66 years old, came to me with an indura-
tion, about two lines wide and half a line thick, at the middle of the florid
margin of his lower lip. The indurated part was slightly sunken, and
covered with a thin yellow scab. This disease had existed two years,
frequently scabbing thickly, then desquamating, never soundly healing;
GROWTH AND ULCERATION. 631
yet it had made no progress. I removed it, chiefly because the patient's
father, when 85 years old, had had cancer of the lower lip ; and be-
cause, if not already cancerous, this could not but be thought a place
very likely to become so. I found, in the indurated tissue, inflamma-
tory products infiltrated among the natural structures of the skin, but
no appearance of epithelial cancer-cells. The cutis was slightly thick-
ened ; but there was no evidence of enlargement of papillae, or of accu-
mulated epidermis ; the scab seemed formed chiefly of dried secretion.
I believe that such a description as this would apply to most of the
warts that precede epithelial cancers of the lower lip, and that we may
justly say of them that they are not cancerous, but are such parts as,
in certain persons, are peculiarly apt to be the seats of cancer. Why
only some among them should become cancerous we can no more ex-
plain than we can why, among so many injuries inflicted, so few should'
be followed by erysipelas or tetanus ; or why, among so many pigmen-
tary moles or nsevi as may be found, only few should become the seats
of melanoid cancer ; or, in a yet nearer parallel, why, when a person
has many such moles, the melanoid cancer should appear in only one.
In these varieties of fate, there is nothing unusual in warts, if we re-
gard them as only predisposed to become cancerous ; but, if we regard
them as the first stages of a cancroid or cancerous disease, such varie-
ties of progress as they manifest would be without parallel.
{e) The general health of patients with epithelial cancer is usually
good, till it is afiected by the consequences of the local disease. Less
than ten per cent, of them appear ill at their first observation of the
disease. No primary cachexia can be observed preceding the appear-
ance of the growth ; nor does a secondary cachexia ensue earlier than
it probably would in any disease of equal duration and severity.
When the formation of an epithelial cancer has once commenced, its
natural course is as regularly progressive tc the destruction of life, as
that of either a scirrhous or a medullary cancer. Only, the rate, and
some parts of the method, of progress are diS'erent.
The average rate of increase of epithelial cancers is less than of
either of the other kinds. It is not apt to be arrested altogether ; yet
it is sometimes so slow that, in a year, the cancer may gain only a line
or two in any of its dimensions. In other cases, however, and espe-
cially when such a cancer has been violently injured, the progress is
much more rapid. I have known three- fourths of the scrotum covered
with ulcerating soot-cancer, and part of the urethra surrounded by it,
in three months after a laceration received while in apparent health ;
in another case, a spheroidal mass of soft epithelial cancer, an inch in
. diameter, formed in the substance of the cheek in two months ; in an-
other, a growth more than an inch in diameter formed in ten weeks ;
in another, the whole depth of the lower lip, and two-thirds of its width,
were occupied with epithelial cancer, in three months after a blow on
682 BPITHBLIAL OANOBB.
a little cancer at its margin ; in another, within twelve months, the
eyelids and a large part of the contents of the orbit were destroyed by
nloeration, and tuberous masses, from one to three-quarters of mo indi
in diameter, were formed under the integuments of the brow, the temple,
and the other boundaries of the orbit.
Cases such as these, and they are not rare, may proye the error of
regarding epithelial cancer as a trivial or an inactive disease in com-
parison with the other forms. Its rate of progress is, like that of scir-
rhous cancer, widely various in different cases ; it has its acute and its
chronic instances. Of its modes of growth, and of ulceration, and of
the usual coincidence of these processes, I have spoken fully in the for^
mer part of the lecture (p. 608) ; I will here only add that the uloera-
tion, at whatever rate, seems constantly progressive. Some portionB
of the ulcer may appear, for a time, as if skinning over, or, portions
of the disease may slough away, and the surfaces they leave may paiw
tially heal ; but I do not remember to have seen any process of healing
or wasting so nearly accomplished in an epithelial cancer, as I. have
described in some cases of both scirrhous and medullary cancer, in the
former lectures (pp. 550, 590).
The progress of the ulceration, and the coincident deepening of the
growth, are usually attended with great pain, — hot, scalding, and widely
diffusing pain ; or with pain like that of neuralgia darting in the course
of nerves. With this, and the constant ichorous discharge from the
ulcer, and the occasional bleedings from ulcerated bloodvessels, the pa-
tient becomes cachectic ; yet probably not sooner than in other diseases
of equal extent, nor in any very characteristic manner.
Primary epithelial cancers are usually single. Two growths may
sometimes appear at once in the same region, as, e, g.y on the prepuce
and glans, or on the scrotum : I have also seen instances of simultane-
ous growth in the eyelid and rectum : the finger and rectum : and the
lip and scrotum ; but such events are so rare, that they may probably
be called accidental. In the later progress of the disease, separate
masses of epithelial cancer may be sometimes found in the tissues, or
cancerous warty growths on the surface, around the primary growth or
ulcer. Healthy tissue appears to intervene between these secondary
cancers and the primary one : and they may be compared with the tu-
bercles so often grouped around a scirrhous mammary gland.
The lymphatic glands, sooner or later in the progress of the disease,
usually become cancerous. I have already (p. 616) described the man-
ner of their infection. I feel almost disposed to think that epithelial
cancer is a much worse disease in this country than in France or Den-
mark, when I see how far my observations on the affection of the lym-
phatics differ from those of Lebert and Hannover. Lebert'^ says that
* Traits Pratique, p. 019.
MULTIPLICITY — EXTENSION. 688
he has found the lymphatic glands affected with '' cancroid" three times
in 81 cases ; and of these 81, 60 were certainly cases of epithelial can-
cer. Hannover'^ has 'even less frequently seen them diseased. Now, in
42 cases of epithelial cancer collected in the ordinary course of hospital
and private practice, and including many in the early as well as in the
latest stages of the disease, I have observed the lymphatics cancerous
twenty times. In the greater part of these cases the characteristic
cancer-structures were found in the glands removed during life or after
death : in the rest, their existence was concluded, with scarcely less
certainty, from the enlargement, with induration, rapid growth, clus-
tering, and destructive ulceration of the glands. It need not be
suspected that in any of these cases the glands were enlarged merely
through ^^ irritation:'* such a state does, indeed, occur with epithelial
as with scirrhous cancer, but the diagnosis of this from the cancerous
enlargement is seldom, in either case, difficult.
I do not suppose that the proportion cited above expresses the
greatest frequency of epithelial cancer in the lymphatic glands. I
believe rather, that very few cases reach their natural end without in-
fection of the glands. Even after the primary disease has been wholly
removed, and when the glands at the time of the operation appeared
healthy, they are frequently, and often alone, the seats of recurrences
of the disease. Sometimes, also, as with scirrhous cancers (p. 534), we
find the disease in the lymphatics greatly preponderating over that in
the primary seat.
My observations are scarcely less different from those of Lebert, in
relation to the occurrence of secondary epithelial cancers in internal
organs. In eighteen autopsies (some of which, however, were made in
fatal cases of rodent ulcer) he has not once found "cancroid growths*'
in any internal part. In seven autopsies,t I have found epithelial can-
cer once in the heart, and once in the lungs : (its appearance in these
parts is described at pp. 618, 619.) Doubtless, the internal organs are
more rarely infected than in any other form of cancer ; but they do not
enjoy an absolute immunity ; the difference between the epithelial and
the other cancers is, in this point again, one of degree, not of kind.
It is a peculiarity of epithelial cancers, that in nearly all the character-
istics of malignant disease, — whether the propagation to the lymphatics
or other organs, the extension to deep-seated parts, the recurrence after
* Das Epithelioma, p. 24.
f In two of these the disease had not reached its natural end; for the patients died in
consequence of amputation. In another case I found epithelial cancer of the torif^ue, with
medullary cancer of the cervical glands, and of the lungs; but, as I have already said (p.
617), though no medullary cancer-structures were found in the primary disease, it was im-
poMible to prove that they had never existed, for a large portion of the tongue had sloughed
before death. Yirchow's observations on the occurrence of secondary epithelial cancer in
internal organs are very clear.
41
634 EPITHELIAL CANCER.
removal, or the rate of progress towards death, — greater differences are
noted according to the seat of disease than among the medullary can-
cers of different parts. The anatomical characters of the disease are
in all parts essentially the same, but their history, in all the particulars
noted above, differs, so as to justify the expression that the disease is
less malignant in some parts than in others. It is, generally^ most ma-
lignant in the tongue, the interior of the mouth, and the penis ; least in
the lower extremities and the scrotum ; in general, also, the epithelial
cancers that are deep-seated are more malignant than the superficial.
These diversities make it very difficult to assign the average duration
of life in persons with epithelial cancer ; and the difficulty is greatly
increased by the recorded cases being often mixed or confounded with
those of other cancers and of rodent ulcers. Taking cases with clear di-
agnosis, without regard to the parts affected, the average duration of
life in twenty-three cases which ran their natural course was 27.4
months ; and in thirty-five cases in which the disease was once or more
removed by operation, 57.6 months.
The following table will show the durations of life in the cases, and
may be compared with those on p. 555, and p. 593, from which the fore-
going statement was derived :
Duration of Life.
Less than 6 months, ....
Number of OftMt.
With Operfttion. WUIumt
0 1
Between 6
" 12
and
12 months, .
18 " ...
1
5
6
6
18
l«
24 " ...
4
r
24
(h
36 "...
3
4
3
4
4 years,
6 *' ...
4
8
3
0
6
More than 8
" 8 '•
years,
1
9
0
2
35 23
The chief point which this table shows, in contrast with those of other
cancers, is in the larger proportion of patients living more than four
years. Great differences, however, as to length of life, may be noted
among the epithelial cancers of different organs. Those in the tongue
rarely survive more than four years ; those in the trunk or limbs rarely
destroy life in less than three years : a majority of those in the lower
lip survive that period. The age at which the disease commences has
no great influence on its duration. . The average duration among four-
teen patients, in whom it commenced at or below 45 years of age, was
39 months ; that among seventeen, in whom it commenced later, was
45J months ; and the general average duration was not exceeded in
the first list more often than in the second.
A considerable prolongation of life would appear, by the cases I have
collected, to be obtained by the removal of epithelial cancers. The
average advantage, as shown by the foregoing table, is 30 months ; and
COURSB AND DURATION OF LIFE. 635
although this great difference may be ascribed to a careful selection of
cases, jet the average is sometimes greatly surpassed. I have seen a
man whose leg was amputated twenty years previously for epithelial
cancer, commencing in or beneath a scar, and he was still well. A
sweep was some time back in St. Bartholomew's with a small scrotal
cancer, from whom one of the same kind was excised thirty years pre-
viously. Of another, Mr. Curling* gives a history extending over
twenty-two years, and including five operations. A man from whom
Mr. Lawrence removed a cancer of the lip remained well for nine years,
and then the disease appeared in the lymphatic glands.
Gases such as these must, however, be considered very rare. Too
much regard to them, and the confusion of the rodent ulcers with the
epithelial cancers, have led to a common belief that recovery or long
life may be promised as the consequence of operations. Such a promise
will not prove true : and yet, as a general rule, the opera,tion is to be
advised, whenever the whole of the disease can be removed without
great risk of life, or of producing worse deformity than already exists.
For (1) though the instances of operations followed by long immunity
from the disease are very rare, yet, in certain cases, these results may
be hoped for. This is especially the case, I think, with the epithelial
cancers of the lower extremity, which follow injury, and for which am-
putation is performed ; with the more superficial cancers of the lip ; and,
most of all, with the soot-cancers which are not making quick progress.
On the other side, according to present experience, such lengthening
of life can rarely be hoped for after operations for the epithelial can-
cers of the tongue, the gums, or other parts in the interior of the
mouth. The best instance of these that I have yet known, is one of a
removal of an epithelial cancer of the tongue, in which eight years
elapsed before the recurrence.
(2) In the majority of cases, and even when very little increase of
life can be hoped for, the removal of the disease may give great comfort
for a time. In general, also, the greater part of the time that inter-
venes between the recovery from the operation and the recurrence of
the disease may be reckoned as so much added to life ; for although we
cannot deny a diathesis, or specific constitutional affection, in epithelial
cancers, yet it is by the progress and consequences of the local disease
that, in the majority of cases, the time of death is determined ; so that,
while local disease is absent, life may be shortening at scarcely more
than the ordinary rate. Of course, in applying such a rule as this
may suggest in practice, we must except from it certain cases in which
the general health is already very deeply affected, or in which the opera-
tion would be perilously extensive.
(8) The extension of the epithelial cancer to the lymphatic glands is
not an insuperable objection to operations. The disease usually re-
* On Diseases of the Testis, p. 535.
flS0 SPITBBLIAL CARCIK.
maiDB long limited to the glands which are Dearest to its primuj mu
(p. 616) ; its complete removal cnn therefore be ium»)lj accompUtbtd ;
and, although I cun cite do instance of very long sorvival mfimr npen-
tion including cancerous glands, yet, on the other aide, I can cit« mm
which would prove that the recurrent disease is quicker or nior« Mvtn
after such operations, than it is after those of equal extent in wUd
the glands are not yet diseased.
(4) The general rule concerning operations in cases of mwoB
epithelial cancer may be the same, I think, as for the pnmary diiMia
A second operation is, in general, lees hopeful than a first, jrel M
always so ; for although the epithelial, like other cancers, q&imIIj ml*
progress at an accelerating rate, yet cases are not wanting in wkieh ik
intervals between successive operations have progressively iiiiiianJ
(5) The recurrence of epithelial cancer after operation is is «■«
cases very rapid, in others greatly retarded. The namber of nsetii
which recurrence ensues at a medium period appears oompantnilj
small. I cannot explain the fact, if it be one, liut I beliera tkuit
afler operation, a patient remain free for eighteen months, it isnr;
probable that the immunity will continue for at least fire years.
Let me now collect from the facts of this lectnre the gnmndiwUii
seem to Justify the inclusion of this disease under the name of oawcr-
It is not unimportant to do so ; fur we may be certain that, id lliisoMt,
the name of the disease will often guide the further study and ifcatTM-
ment of it.
I have excluded from the group of epithelial cancers the rodioit ricM^
which M. Lebcrt includes with them under the name of "eaacni4."
The two diseases are so constantly unlike, in both structure and iaitmj
(see p. 621), that their separation under different titles Beena eooMtmi
with the most usual rules of nosology. I have also exelndod tboMffe-
pillary and other affections of the skin, in which epidennoid ■tittiw
are accumulated only on the surface of the affected part. For, altlMafh
these may sometimes appear like the €rst stages of certain «pitM>al
cancers (see pp. 601 and 630), yet the distinction belwwii the tmit
commonly well markeil in the history of each case; and, id tbtiri^
spective anatomical relations, the distinction between a snpeHmliit
an interstitial epidermoid structure is very significant ; since tht fiNM
has its nearest homologue in natural epithelia, the latter in mmW
infiltrations.
Thus limiting the diseases to he included under it, the name of if^
thelial cancers seems justified by their conformity with ibe adnhv
and medullary cancers in these following respects :
(I) The interstitial formation of structures like those of epitlufw ■*
not an imitation of any natural ti&sue; it constitatca a }iet*nhf'»
structure ; for superficial position is more essential to the type nffp*-
thelial structures, than any shape of elemental cells or
EPITHELIAL CANCER. 687
(2) Even that delusive appearance of homology, which exists when
the structures like those of epithelium are formed in the dermal tissues,
and therefore near the surface, is lost in nearly all the cases of deep-
seated epithelial cancers, and in all the similar affections of the lym-
phatic glands and internal organs.
(3) The interstitial formation of cells in epithelial cancer is conformed
with the characteristic plan of all cancerous infiltrations, and leads to
a similar substitution of new structures in the place of the original tis-
sues of the affected part.
(4) The interstitially formed cells often deviate very widely from the
type of any natural epithelial cell, in shape, in general aspect, in method
of arrangement, and in endogenous formation (p. 612, e. s.). The dif-
ference between them and any natural elemental structures is, indeed,
much greater than that between many medullary and scirrhous cancer-
cells, and the cells of the organ in which they grow : e. g.j it is some-
times difficult to distinguish the cells of a medullary cancer in the liver
from those of the liver itself.
(6) The pathology of epithelial cancers is scarcely less conformed
than is their anatomy to the type represented by the scirrhous and me-
dullary cancers ; for, not only are they prone to incurable ulceration,
and to repeated and often very rapid recurrence after removal, but
(which is much more characteristic) they usually lead to the formation
of structures like themselves in the lymphatic glands connected with
their primary seat; they lead sometimes to similar formations in more
distant organs (p. 616, e. s.); and the average duration of life in pa-
tients affiected with them, is, on the whole, not greater than that of
those who have scirrhous cancer.
(6) In their growth, and in their recurrence, there is no tissue which
the epithelial cancers do not invade and destroy (pp. 604 and 609).
(7) A peculiar liability to them exists in members of those families
in which scirrhous or medullary cancer also occurs (p. 626).
Such are the affinities between the epithelial and (as I would say) the
other cancers. They are so numerous and so close, that I cannot but
think we should be guided in the choice of a name by them, rather than
by any other consideration. They are surely more significant of affinity
with the other cancers than the contrast between the shapes of the ele-
mental cells is indicative of such difference as should be expressed by a
different generic name.
638 MELANOID AND OTHER CANCERS.
LECTURE XXXIIL
MBLANOID, H^MATOID, OSTEOID, VILLOUS, COLLOID, AND FIBROUS
CANCERS.
Op the three chief forms of cancer which I have now described, we
may observe, I think, that though two of them* may be mixed in one
mass, or may occur at different times in the same person, or in different
members of the same family, and though there are forms intermediate
and transitional between them, yet a mass of one of them does not, by
any transformation, assume the characters of another. A scirrhous
cancer, I think, never itself becomes medullary or epithelial ; neither
does the converse happen ; nor do we see any indication that interfe-
rence with the development of a cancer of either of these forms would
lead it into the assumption of the characters of another. Combination,
coincidence, succession, or interchange of these three forms may be
found ; but, I believe, no transformation of a growth completed or in
progress.
If this be true, it indicates that the degree of difference between each
two of these three forms is greater than that which exists between them
and the cancers to which I shall devote this lecture. For there seems
suflScient reason to believe that, by certain generally recognized pro-
cesses of degeneration or disease, a medullary or epithelial cancer may
become melanoid, or haematoid ; that a scirrhous or firm medullary
cancer may become osteoid ; that the colloid character may be, in some
measure, assumed by either of the three chief forms; and that either
of them may observe the villous or dendritic mode of growth. It need
not always be supposed that, in the transformations here implied, the
cancer-structures already perfected change their characters. It is pro-
bable, indeed, that such changes do occur in some of the instances we
have to consider ; but, in others, we may rather believe that the pecu-
liarities of structure are due to something which induces degeneration
or disease in the cancer-elements in their most rudimental state.
The belief that the six forms of cancer, whose names head this lec-
ture, are modifications or varieties of one or more of the three already
described, may justify my describing them more briefly, and, in many
parts, by terms of comparison with the chief forms. Or, if this belief
be not a good reason for such a course, it must be sufficient, that the
examples of all these six forms are so rare, that complete and indepen-
dent histories of them cannot, at present, be written.
It is, I think, probable that other groups of cancers besides these
might be conveniently described as varieties of the principal kinds;*
* This may be the case with what Mflller named Carcinoma fasciculatum seu hyalinum.
But, judging from his description and Schuh's, I cannot tell whether it is a disease which I
have not yet seen, or whether (as I am more inclined to believe) the name has not been
HBLAHOID CANCEB — STRDCTDRE.
bat, at present, it seems better to defer the introduction of aew names
till ve hare attained more accurate knowledge.
MBLANOID CANCER.
The Melanotic or Melanoid Cancers are, with very rate exceptions,
medullary cancers modified by the formation of black pigment in their
elemental stmctares. On this long-disputed point there can, I think,
be no reasonable donbt. I have referred to a case of melanotic epithe-
lial cancer (p. 616) : but, with this exception, I have not seen or read
oF any example of melanosis or melanotic tumor in the human subject,
which might not be regarded as a medullary cancer with black pigment.
In the horse and dog, I believe, black tumors occur which have no can-
cerous character ; but none such are recorded in human pathology. The
conditions, which some have classed under the name " spurious mela-
nosis," are blackenings of various structures, whose only common cha-
racter is that they are not tumors.
Melanotic cancers may hare the general characters of any of the
varieties of the medullary cancer ; but the primary growths are rarely
either very firm or very soft. They may appear as infiltrations ; but
are more often, I think, separable masses. Their characteristic pigment
marks them with various shades of iron-gray or brown, deepening into
deepest blackness. The pigment is variously arranged in them. Some-
times, we see, on the cut surface, a generally difTused brownish tint,
derived from thickly sprinkled minute dots: sometimes, a whole mass
IB uniformly black : sometimes, one or more deep black spots appear in
the midst of a pure white brain-like mass :
sometimes (as in the specimen here figured),
in half a tumor there are various shades of
brown and black, in the other half the same
texture uncolored : sometimes a whole mass
is, as it were, delicately painted or mapped, as
with Chinese ink. There are thus to be found,
in melanoid cancers, all plans and all degrees of
blackening ; and these diversities may be seen
even in different parts of the same tumor, or
in different tumors in the same person.t Nay,
even in cancers that look colorless to the naked
eye, I have found, with the microscope, single
cells or nuclei having the true melanotic cha-
racters. And both the general and the mi-
croscopic aspect of the disease may be yet
applied to M>me specimenB of the tott, flickering, matnniary or pnroticl glandular iiiinorB or
to the mammary piolireroii) cysts thai are prone to recur (see pp tS6 4S7)
* Fig. 106. Section of a variously shBded melanoid cancer formed beneath a mole or
pigroeDtary imvus. Museum of Si. Dntlholo mew's. Natural size.
f All tbcM varieties are illustrated in the Museums of [he College and St. Bariliolomew's,
I* nfMTed to in the Indices of tha Catalogues, vol. i, p. 133, and vol. i, p. 14.
Fig. 100.«
640 MELANOID CANOSR.
further diversified by the coincidence of degenerations or hemorrhages,
producing, in the unblackened parts of the tumors, various shades of
yellow, or of blood-color.
In the dark turbid creamy or pasty fluid that may be pressed from
melanotic cancers, the greater part of the microscopic structures are
such as might belong to an uncolored medullary cancer. It is often
remarkable by how small a proportion of pigment the deepest black
color may be given to the mass : a hundredth part of the constituent
structures may suffice. The pigment is generally in granules or mole-
cules : but it is sometimes in nuclei or in corpuscles like them.
The majority of the pigment-granules are minute particles, not much
unlike those of the pigment-cells of the choroid membrane. When out
of focus, they appear black or deep brown ; but, when in focus, they
have pellucid centres, with broad black borders. They appear spheri-
cal ; and usually the majority of them are free, i. e., not inclosed in
cells, and vibrate with molecular movement in the fluid that suspends
them. The greater part of the color depends on these free granules
(Fig. 107) ; but others like them are inclosed in the cancer-cells, or,
Fig. 107.*
^^B^
more rarely, in nuclei. Sometimes those in the cells are clustered
around the nucleus ; sometimes they are irregularly scattered ; in either
case, they appear as if gradually increasing till they fill the cell, and
change it into a granule-mass, which, but for its color, we might exactly
compare with the granule-masses of fatty degeneration. While the
pigment-granules are thus collecting, the nucleus remains clear ; but at
last, when the cell appears like a granule-mass, it is lost sight of.
After this, moreover, the masses formed of pigment-granules may
break up, and add their granules to those which we may suppose to
have been free from their first formation. The completely melanotic
cells and their corpuscles, seen singly in the microscope, look not black,
but rusty brown or pale umber-brown : like blood-cells, it is only when
amassed that they give the full tint of color.
With the melanotic granules, there is sometimes a much smaller
number of particles of the same color, and the same apparently simple
structure, but of larger size: from ^oVoth to ^o*ooth of an inch in
* Fig. 107. Elemental structures of melanoid cancer, referred to in the text. Magnified
350 times.
PATHOLOGY. 641
diameter. These may be- both free and in cells; in the latter case,
lying mingled with melanotic granules in the contents of the cell.
More rarely, corpuscles like the nuclei of cancer-cells, preserving their
shape, sise, and apparent texture, present the characteristic brown tint.
Such corpuscles may be free ; but they may also occupy the place of
nuclei in cells, whose other contents are either uncolored or mixed with
pigment-granules : and more rarely, a single corpuscle of the same
kind may be seen in a cell containing an ordinary colorless nucleus.
In aU the main facts of their pathological history, the melanotic can-
cers are in close conformity with the medullary : and this may be
reckoned among the evidences that there is much less difference be-
tween these two forms than there is between the medullary cancers and
either the scirrhous or the epithelial.
In the tables of 865 cases of cancer from which those in the foregoing
lectures were derived, there are 25 cases of melanoid cancer. Seven-
teen of the patients were females, 8 were males. In 14 cases, the
primary seat of the disease was in the skin or subcutaneous tissue ;
in 9, in the eye or orbit; in 1, in the testicle; in 1, in the vagina.*
In this limitation to a few primary seats, and in its proneness
to affect certain abnormal parts of the skin, are the chief peculiari-
ties of this variety of cancer ; but on the other points which may be
settled by counting, I might have added the 25 cases to those of ordi-
nary medullary cancer, without disturbing the results stated in Lecture
XXXL
Thus, the ages of the patients at the access of the cancer were as
follow :
2
1
7
4
5
4
2
The only notable difference in this table, when compared with that
at page 582, is in the inferior proportion of cases before 20 years of
age ; a difference mainly determined by the large number of cases of
uncolored medullary cancer of the eye in children. f
Among 10 patients with melanoid cancer, one had had a relative who
died with cancer of the breast ; another had many relatives with pig-
mentary nsevi like that in which her own cancer originated. In another
group of 10 cases 3 had had cancerous relatives.
* 1 ODcesaw primary melanotic cancer of the liver; but I have no complete record of the
Under 10
years,
Between 10 and 20
20 " 30
30 " 40
*• 40 « no
" 50 " 60
Above 60
t This fact is corroborated by one of the tables in Mr. Pemberton's " Observations on
Melanoeis," 1S57, p. 18; an essay containing the results of the records of sixty cases of
melanoAis.
642 MELANOID CANCER.
In 20 of the cases, the prerious history of the affected part is re-
corded. In 3 of those in which the eye was affected it had been mor-
bidly changed by preyious inflammatory disease ; in 2 it had appeared
healthy. Among the 14 cases affecting the skin or subcutaneous tissue,
one patient assigned no local cause ; 2 referred to injury, and were un-
certain of the previous condition of the skin ; in 10 the disease com-
menced beneath a congenital pigmentary nsevus, or dark mole ; and
in 1, in what the patient called a wart of several years* standing.* I
shall presently revert to these facts.
In regard to their rate and method of growth, their ulceration, and
their multiplying in parts near and distant from their primary seat, I
believe the general history of the melanotic cancers is parallel with that
of the medullary given in a former lecture (p. 585, e. s.). But they
present even a greater tendency to multiply in the subcutaneous tissue,
growing here in vast numbers of small soft tubercles.
In like manner, the duration of life in melanotic nearly corresponds
with that in medullary cancers. In 18 cases, in all of which the pri-
mary disease was removed (but in two only partially), the durations of
life from the first notice of the cancer were as follow (and the table may
be compared with that on p. 694) :
Between 6 and 12 months in 3 cases.
" 12 " 18 " 4 "
" .24 " 36 " 5 "
" 36 "48 « 1 «
Above 48 " . 5 "
Among 18 cases, whose history is known for some time after the re-
moval of the primary disease, one has survived for three years, another
for ten months, without recurrence of the disease. In the rest the dis-
ease recurred at the following periods (compare p. 594) :
Between 1 and 3 months in 7 cases.
i(
3
It
6
((
4
((
u
6
((
12
u
2
li
.(
12
k'»
24
u
2
li,
i(
24
U
3G
(k
1
ti
Seeing this close correspondence in their general pathology, the rules
respecting operations for mclanoid cancers must be the same as for the
medullary. (See p. 595.)
I have reserved for separate consideration some of the peculiarities
of mclanoid cancers. Three things in them especially deserve reflec-
tion, namely : (1) their color ; (2) their proneness to take their first seat
in or near cutaneous moles ; (3) their profuse multiplication.
1. The color of the melanoid cancers is due to a pigment-formation,
* Of Mr. Pembertons 34 cases of melanosis of the skin, 15 commenced "in or near •
coDgcnifal mole, wart, or mark."
PATHOLOGY. 648
correspondiDg with that which we find, in the normal state, in the pig-
ment-cells of the choroid membrane, and in the rete mucosum of colored
skin^. Their usual primary occurrence near these seats of natural
pigments may, therefore, be regarded as an illustration of the tendency
of cancers to conformity, at least sometimes and in some respects, with
the characters of the adjacent natural textures.
But another meaning of the pigment in melanotic cancers is suggested
by its likeness to that which accumulates in the lungs and bronchial
glands in adyancing years, and in the darkening cuticle of many old
persons. The coloring particles are probably different in these cases ;
they produce different shades or tinges of blackness, but their plans of
formation and arrangement are in all similar. And the analogy of
their formation in the aged, a^d in some other instances (p. 84), may
warrant us in regarding melanosis as a pigmental degeneration of me-
dullary cancer. The chief characters of its minute structures agree
with this, especially the gathering of pigment-molecules about the nu-
cleus, their gradually filling the cell-cavity, till, both the nucleus and
the cell-wall disappearing, the nucleated cell is transformed into a dark-
colored granule mass. In all these characters there is an exact parallel
between the transformations of the cells in melanoid cancers and the
usual changes of the fatty degeneration. (Compare p. 528 and p. 611.)
2. The proneness of melanoid cancers to grow first in or beneath pig-
mentary moles is very evident ; and I am not aware that such moles are
peculiarly apt to determine the locality of any other tumors ; for, ex-
cept a case (p. 600) in which an epithelial cancer grew from one, I
have met with no instance of other than melanoid cancers connected
with them.*
The fact is, I suppose, quite inexplicable ; but it may be usefully
suggestive. It seems a striking illustration of the weakness in resist-
ing disease which belongs to parts congenitally abnormal. It seems,
also, to be an evidence that a part may very long remain apt for the
growth of cancer, and not become the seat of such a growth, till the
cancerous diathesis, the constitutional element of the disease, is esta-
blished. And this event may be very long delayed : as in a woman, 80
years old, whom I saw with a large melanotic tumor, which had lately
grown rapidly under a mole that had been unchanging through her long
previous life. But again, this peculiar affinity (if it may be so called)
of moles for melanoid cancers, may make us suspect that there may be
other, though invisible, defects of first formation in our organs, which
may render them, or even small portions of them, peculiarly apt for
the seats of malignant and other specific diseases. It is often only the
color that makes us aware of the peculiarity of that piece of a man's
* Pirofn>ff (Elinische Chirurgie, H. i, p. 34) relates three cases of removal of na*vi (an-
giektatie), which was followed by growth of medullary cancers, at or near the seat of ope-
ration. They all appear to have been medullary, not melanotic, cancers; but the third case
may have been melanotic.
644 MELANOID CANCER.
skin in which cancer, if it ever occur in him, will be most likely to
grow : and yet color is so unessential a condition of texture, that we
may well believe that all the more real conditions of such liability to
cancer may be present without peculiarity of color, though, being with-
out it, the part in which they exist may not be discernible.
I have spoken of the pigmentary moles as becoming the seats of me-
lanotic cancers. It might seem as if the mole were, in some sort, the
first stage of the cancer ; but it is not so : the structures and the life of
the mole are those of natural skin and epidermis, abnormal in quantity
and color, but in no more essential properties : there are no structures
in moles like those of cancer till, at a certain and usually notable time,
cancer begins to be formed in them. And here let it be observed, how
close is the correspondence in these respects between the pigmentary
moles, and the warts that are apt to become the seats of epithelial can-
cers (p. 628). The patient is usually aware of the time at which a
mole, observed as an unchanging mark from birth or infancy, began to
grow. In some instances the growth is superficial, and the dark spot
acquires a larger area and appears slightly raised by some growth be-
neath it : in other cases the mole rises and becomes very prominent or
nearly pendulous. I believe that when the mole becomes thus promi-
nent, the chief seat of the cancerous formation is in the superficial layer
of the cutis and in the place of the rete mucosum ; and that when it
only extends itself, the cancerous growth is chiefly in the skin and sub-
cutaneous tissue. In the former case, the cancer-structures are usually
infiltrated among the natural structures of the affected part ; in the
latter, they generally form a distinct tumor, which may be dissected
from, though it is closely connected with the surrounding tissues and
the thinned layer of cutis and dark cuticle that covers it. (Fig. 106,
p. 639.)
The general characters of the growths thus forming correspond, I
believe, in every respect with the medullary cancers of the skin and
subcutaneous tissue (p. 579): color alone distinguishes them ; they are
equally prone to multiplicity. Often in removing a deep-set melanotic
mass, smaller masses are found imbedded in the adjacent fat or other
tissue, and sometimes the formation of one or more subcutaneous growths
almost exactly coincides with the outgrowths of the mole and its occu-
pation by the cancer-structures.
3. The multiplicity of secondary melanoid formations is often very
striking. I have, indeed, seen one case in which, to the last, only the
lymphatic glands connected with the primary growth were diseased ;
and another in which only the liver and some lymphatics were affected;
but the more frequent issue of the cases almost literally justifies the
expression that the disease is everywhere. Are we to conclude from
this that the multiplication of melanoid cancers is more abundant than
that of the medullary cancers, which in other respects they so closely
resemble ? I think not. We can easily see all the secondary melanoid
HiBMATOID CANCER. 645
formations, even the smallest and least aggregated ; and it is often the
color alone that draws attention to many which, but for it, we should
not have noticed. I suspect that equally numerous formations exist in
many cases of medullary cancers, but are unseen, being uncolorcd.
HJEMATOID CANCER.
This name may perhaps be retained to express a form of cancer
which Mr. Hey had chiefly in view when he proposed the name of Fun-
gus Hsematodes.* It is most probable that all the cases to which he
gave this name were soft medullary cancers; and his attention was
especially directed to the fact that when the morbid growth protrudes
through the skin, the protruding portion may have such a shape as, in
the conventional language of surgery, is called fungous, and often
bleeds largely, and is so vascular, or so infiltrated with blood, that it
looks like a clot.
The identity of the fungus hsematodes of Hey with the medullary
cancers was fully recognized by Mr. Wardrop and others ; but unfor-
tonately, certain foreign writers, regarding the hemorrhage as the dis-
tinctive character of the disease, included under the same term nearly
all severely bleeding tumors, of whatever kind.f It was an unhappy
misuse of Hey*s name, by which he meant to express, not a bleeding
growth, but one like a clot of blood : and it led to a confusion which is
still prevalent.
Leaving the term fungus haematodes, we may employ that of haema-
toid cancer, for such as are like clots of blood through the quantity of
blood that they contain. The likeness is indeed, I believe, only an acci-
dental one, due to hemorrhage into the substance of the cancer, from rup-
ture of some of its thin-walled bloodvessels. It seldom exists in the whole
mass of a cancer; but usually, while some parts have the ordinary as-
pects of medullary or some other form of cancer, other parts are blood-
like. The best illustration of the disease that I have seen is in a large
tumor,! of which one-half might be taken as a good type of the brain-
like medullary cancer, and the other half as an equally good type of the
htematoid. This ^alf had been deeply punctured during life ; it had
bled very freely, and the simultaneous bleeding into its own substance
had, doubtless, changed it from brain-like to blood-like.
Probably any cancer may thus be made haematoid ; but the change
* Observations in Surgery, p. 239.
f Among the cases thus confused are some strange ones of profuse bleedings from sup-
posed growths, of which little or nothing could be found after death. Such a case is re-
lated by Mr. Abemethy (On Tumors, p. 127 — note) ; and a specimen from Mr. Liston^s
Maseum is in the Museum of the College, 302 a. It is perhaps impossible at present to
My what these diseases were; but 1 suspect they were medullary cancers with bloodves-
sels excessively developed, like those of an erectile tumor.
X Mds. of St Bartholomew's, Ser. xxxv, No. 28.
646 OSTBOID CANCBR.
is peculiarly apt to happen in those which are of the softest texture and
most rapid growth, and which are situated where they are least sup-
ported by adjacent parts.
OSTEOID CANCER.
Miiller assigned the name of osteoid tumor, or ossifying fungous
growth,* to a form of disease of which, with admirable acumen, he col-
lected several cases illustrating these as its distinctive characters, —
that the primary tumor consists chiefly of bone, but has, on its surface
and in the interstices of its osseous parts, an unossified fibrous consti-
tuent as firm as fibrous cartilage ; and that, after a time, similar growths
ensue in parts distant from the seat of the first-formed, and not on
bones alone, but in the areolar tissue, serous membranes, lungs, lym-
phatics, &c. Mr. Stanleyt has described the same disease under the
name of Malignant Osseous Tumor ; and single examples of it may be
found under the names of periosteal exostosis, fibrous osteo-sarcoma,
foliated exostosis, &c. Muller was disposed to call it osteoid cancer;
and certainly this name is best suited to it, its intimate affinity with
the other forms of cancer being evident in these things, — (1) its corre-
spondence, in nearly every particular of structure and of history, with
the characters of cancerous disease, as exemplified in the scirrhous and
medullary forms; (2) its not unfrequent coexistence with medullary
cancer of the ordinary kind, either in a single mass of tumor, or in
different tumors in the same person ; (3) the uninterrupted gradations
between it and the scirrhous and medullary cancers ; (4) its mutations
with the same, in hereditary transmission or in secondary productions.
I cannot doubt the propriety of calling a disease cancer, in which these
facts can be demonstrated ; and I believe that the most probable view of
the nature of osteoid cancers would be expressed by calling them ossified
fibrous or medullary cancers, and by regarding them as illustrating a
calcareous or osseous degeneration. (See p. 540, and compare p. 87.)
The primary seat of osteoid cancer is usually some bone ; but it is
not limited to bones. In a case by Pott,J quoted by Muller, the pri-
mary tumor lay " loose between the sartorius and vastus internus mus-
cles.'* In the Museum of St. Thomas's Hospital there is a tumor like
an osteoid cancer, which was removed from near a humerus, and another
from a popliteal space. In all these cases, the removal of the tumor
was followed by the growth of medullary cancers with little or no bone
in them.
Among the bones, the lower part of the femur is, with remarkable
* Ueber ossificirende Scliwamme, oder Osteoid-Geschwulate (Miiller's Archiv, 1843,
p. 39C).
f On Diseases of the Bones, p. 1G3.
J Works, by Earle, iii, 313. I think that No. 24-29 A in the College Museum may be re-
garded as an osteoid cancer of the testicle, though the bone-like substance has not the cha-
racters of perfect bone.
STRUCTURE. 647
predominance, the most frequent seat of osteoid cancer. Among 27
cases, of which I have seen histories or $pecimens, 15 had this part for
their seat : the skull, tibia, humerus, ilium, and fibula, were each af-
fected in two cases, and the ulna and metacarpus each in one case.
In most cases, the osteoid growth occurs coincidently within and on
the exterior of the bone, following herein the usual rule of medullary
cancers ; but it may exist on the exterior alone : and I have twice seen
its fibrous basis in the cancellous tissue of a bone, of which the exterior
was surrounded with soft medullary cancer.
In the best examples of osteoid cancer, i. e, in those in which its pe-
culiar characters are most marked, it presents, if seated on a long bone,
such as the femur, an elongated oval form ; if on a flat bone, a bicon-
vex form. Its elongated shape on the femur, the swelling gradually
rising as we trace down the shaft, and then rather less gradually sub-
siding at the borders of the condyles, is almost enough for a diagnosis
of the osteoid cancer from other hard tumors. It is like the enlarge-
ment produced by simple thickening of the bone or periosteum : a like-
ness which is increased by the smoothness of surface, the nearly incom-
pressible hardness, and the considerable pain, which, in general, all
these swellings alike present.
When we dissect down to an osteoid cancer (taking one on the femur
for a type) we usually find the adjacent tissues healthy, except in being
stretched around the swelling. Small masses of firm cancer may, how-
ever, be imbedded in them, distinct from, but clustered around, the chief
mass. The periosteum is usually continued over the cancer, but scarcely
separable from it. The surface is smooth, or very lowly and broadly
tuberous. A section generally shows that the exterior of the growth
is composed of a very firm, but not osseous substance ; while its inte-
rior part, t. e. that which lies nearest to the shaft, and that which is in
the place of the cancellous tissue, is partially or wholly osseous. The
two substances are closely interblended where they meet ; and their
relative proportions differ much in different specimens, according to the
progress already made by ossification.
The nnossified part of the tumor is usually exceedingly dense, firm,
and tough, and may be incompressibly hard ; its cut surface uprises
like that of an intervertebral fibrous cartilage, or that of one of the
toughest fibrous tumors of the uterus. It is pale, grayish, or with a
slight yellow or pink tint, marked with irregular short bars of a clearer
white ; rarely intersected as if lobed, but sometimes appearing banded
with fibres set vertically on the bone.
The bony part of the tumor, when cleared by maceration, has charac-
ters altogether peculiar (Fig. 108). In the central parts it is (in the
best-marked specimens) extremely compact, scarcely showing even any
pores, white and dry. To cut, it is nearly as hard as ivory, yet, like
hard chalk, it may be rubbed or scraped into fine dry powder. At its
Pig. 108.«
648 OBtEOID CANCER.
periphery it is arranged in a knobbed and tuberous form, the knobs
being often formed of close thin gray or white lamelln, whose present-
ing edges ^ve them a fibrous look, ex-
actly like that of pumice-stone. In this
part, also, the bone is very brittle, flaky,
and pulverulent.
In some specimens, the whole of the
bone has this delicate lamellar and brittle
texture ; but more generally, as I have
said, the central part is very hard, and
this, occupying the walls and cancellous
tissue of the shaft, equally with the sur-
rounding part of the tumor, makes of the
whole such a compact white chalky mass
as the sketch here represents (Fig. 108).
In the osteoid cancers of the lymphatic
glands (Fig. 109), and other soft parts,
the bone is finely porous, spongy or reti-
culated ; or it may be finely lamellar, and
look fibrous on its surface.
It is always soft and brittle, and, often,
it has in these parts no regular plan, bat
is placed in small close-set grains or spi-
cules, which fall apart in maceration. In
whatever plan or part the bone is fonnd,
it has no medulla; its interstices are filled with cancer-substance.
When the salts of lime are removed from the bone with acid, an or-
ganic basia-substance remains, whidi
presents the same general aspect ss
the unossified part of the cancer, while
retaining the lamellar and fibrous ar-
rangement of the bone. I This basis
yields gelatine ; and the saline con-
stituents are similar to those of ordi-
nary bone, but with a disproportionate
preponderance of phosphate of lime
(Miiller, I. c. p. 412).
With the microscope, the unossified part of an osteoid cancer appears
fasciculated or banded, and is always very difGcult to dissect. In some
specimens, or in some parts, it has only a fibrous appearance, due to
markings and wrinkles of a nearly homogeneous substance, in which
* Fig. 108. SecTionoflheoeseous panoran (HieoJd Fsncerof Ihefemiir. Muhuid of
Si. Bartholomew's, Set. i. lOD.
t Fip. 109. Swiion of an inguinal lymtilialic gland, wiih osleoiti cancer, sTter m»cen-
tion. Nulural size. Mu9, of Sl Banholomew's, Ser. i. No. t09.
X MuB, Coll. Surg., No. SOS.
Fig. 109.t
MICROSCOPIC STRUCTURE. 649
abundant nuclei appear when acetic acid is added. In others, it is dis-
tinctly fibrous, but not in all parts with the same plan. The fibres are
sometimes moderately broad, about 31/oo^h of an inch wide, have uneven
thorny edges, and, arranged in bundles, look like fagots (Fig. 110, a).
Fig. 110.*
In other parts they are finer, like sharp-edged, crisp, and stiff fila-
ments. Such as these may present a nearly regular reticular arrange-
ment, with well-formed meshes (b) ; or they may be nearly parallel,
and construct a more distinctly fibrous texture (c) ; or they may be
closely matted, and, except in their exceeding toughness, may be like
the short, crooked filaments of a fibrine-clot (d). I never saw them
presenting the undulating glistening aspect of the filaments of an ordi-
nary fibrous tumor, or of natural fibrous tissue.
Fibrous tissue, in one or other of the forms just mentioned, makes up
the main mass of the unossified part of the cancer. But other elemen-
tary forms usually exist with it. Sometimes cancer-cells are mingled
with it, as if imbedded in the interstices of the fibres. They are of
ordinary form, not differing fpom those of common scirrhous cancers in
anything, unless it be in that they are smaller and less plump. Some-
times granule-masses and minute oil-molecules are scattered among the
fibres. Both these and the cancer-cells appear foreign to the fibrous
tissue, as mingled with it, not part of it ; but, if acetic acid be freely
added, the fibrous tissue becomes clearer, and we find (what may before
have been very obscurely seen) abundant nuclei imbedded in it. They
are generally oval, smooth, well-defined, from ^o'cu^li to ^s'oD^li of ^n
inch in length ; but, I think, as the fibrous tissue becomes more perfect,
they shrivel and become crooked, or like little stellate cracks in the
basis-substance ; or else that, as it ossifies, they are imbedded in the
accumulating lime-salts, and become the lacunae of the bone.f
Structures such as these exist in the osteoid cancers of all parts ; and
when a series of those occurring in the lymphatics and other organs can
be compared with the primary disease on a bone (for example), I believe
no other difference will be found, than that the secondary cancers are
less definitely fibrous, and have a larger proportion of cancer-cells or
granule-masses, than the primary disease. These, however, are no
* Fig. 110. Fibrous tissue of osteoid cancer in different forms, as described in the text.
Magnified 400 times.
f Gerlacb also describes this in his Essay, Der Zottenkrebs und das Osteoid, p. 52.
42
650 OSTEOID CANCBR.
greater differences than may be found in comparing the less with the
more firm parts of a single primary mass of the disease.
The microscopic characters of the ossified part of the cancer are those
of true bone, but rarely of well-formed bone. In some parts^-espe-
cially in the secondary cancers — that which appears to be done is only
an amorphous granular deposit of lime-salts, like those in ordinary cal-
careous degenerations. In other parts the lacunae of true bone are
distinct, but they are small, and their canalicules are few and short,
and without order. Haversian canals also exist with these, but thej
have not a large series of concentric lamellae like those in normal bone.
In other instances, but these are rare, the lacunae are more nearly per-
fect; their canalicules communicate with one another, and with the
cavities of the Haversian canals. The bone with distinct lacunae and
canalicules is not found exclusively in the primary cancer, or near the
natural bone on which it is seated : here, indeed, the complete bone is
most frequent ; but it may be found, also, in the secondary growths in
the glands and elsewhere. These differences between the bone of the
primary and that of the secondary osteoid cancers, like the similar
differences of their unossified parts, are only differences of degree, such
as may be found in separate parts of the same mass ; they are, probably,
to be ascribed only to more recent or more rapid growth.
The foregoing description of the osteoid cancers may su£Bce to show
that their nearest affinities, judging by the structure of their unossified
part, are to the fibrous cancers, of which I spoke at p. 541, and to the
firmest of the medullary cancers (p. 567). When abundant cancer-cells
are present they most nearly resemble the latter form ; when they are
almost wholly fibrous, the former.* Their peculiarity, as cancers, is in
their ossification. In this they may seem to approximate to the non-
cancerous tumors : but, really, they remain, even when ossified, very
distinct from any of them. I have enumerated (p. 483) the characters
by which they are distinguished from both the hard and the cancellous
osseous tumors ; and the difference is as complete, and, I believe, as
constant, as that of their fibrous basis is from the structure of any non-
cancerous fibrous tumor.
If we consider only their osseous part, the osteoid cancers most nearly
resemble those soft medullary cancers which have the most abundant
internal skeletons. There is, indeed, no absolute line of distinction to
be drawn between the two. It may be very evident, in the typical
specimens of each, that the skeleton of the soft medullary cancer is
formed 'by ossification of the intersecting and overgrown infiltrated
periosteum (p. 566) ; and that the bone of the osteoid cancer is formed
by ossification of the proper cancerous substance ; but, between these
* A case of osteoid cancer is minutely related by Mr. Sedgwick (Br. and For. Me<J. Chir.
Rev., July, ISSf)), in wliich there were secondary formations in the clavicle, thorax, and head,
but the tumors in the head assumed the characters of ordinary encephaloid, which, Mr.
Sedgwick thinks, favors the opinion expressed in the text of the relation of these osteoid
cancers to the medullary cancers.
PATHOLOGY. 651
extremes or types, there are numerous instances in which the two con-
ditions are mingled, or through which the one condition merges into
the other. And this is no more than we might expect, seeing the fre-
quencj with which the osteoid and the medullary disease appear to-
gether, or in succession.
The materials for a general pathology of osteoid cancers are very
scanty ; yet one may be written ; for if we collect only well-marked ex-
amples of the disease, their histories will be found consistent with one
another, and distinct from those of the other groups of cancers.
Among twenty cases, fifteen occurred in men, and five in women : a
preponderance on the male side approximating that observed in epithe-
lial cancers, and (if we may trust to a result from so few cases) con-
trasting, in a striking manner, with the distribution of medullary and
scirrhous cancers.
Among nineteen of these patients, five were between 10 and 20 years
old ; nine between 20 and 30 ; four between 30 and 40 ; one between
40 and 50 : proportions which again do not correspond with those in
any other form of cancer.
Among thirteen of the patients, five distinctlj^ referred to injury as
the origin of the cancer, and two to previous disease in the part : the
others assigned no cause.
The growth of osteoid cancers is generally rapid, and accompanied
with sever^e pain in and about their seat ; their multiplication in the
lymphatics and in distant parts takes place with proportionate rapidity ;
and intense cachexia occurs early in their course. There are excep-
tions to these things ; but in all these respects the majority of the osteoid
cancers appear as malignant as the medullary, and are as quickly fatal.
Among fourteen cases, of which the ends are recorded, three died in
consequeqce of amputations. Of the other eleven, four underwent no
operation, and all died in or within six months from the first notice of
the disease. Of the remaining seven, in all of whom the disease was
once or more removed, and in all of whom it recurred before death,
two died in the first year of its existence, one in the second, one in the
third ; but one lived for seven and a half years, another for twenty-
four, and another for twenty-five years.
In all the instances of speedy death, secondary osteoid cancers ex-
isted, and the result was probably to be assigned to these and to the
coincident cancerous cachexia; for the primary growths have little
tendency to ulcerate or protrude, and they seem to contribute directly
to death by their pain alone. In the instances of life extended beyond
twenty years, the disease appeared to recur only near its primary seat.
The most frequent seats of the secondary, or recurrent, osteoid can-
cers are the lymphatic glands, in the line from the primary seat to the
thoracic duct, the lungs, and the serous membranes : but it is not limited
to these ; it may be found even in the bloodvessels, as in a case which
652 OSTEOID CANCER.
I shall relate, and has been traced in the thoracic dact."*" Its condi-
tion in these secondary seats need not be described : in structure it
resembles in them the primary disease, with only such differences
as are already mentioned ; in plan it is like the growths or infil-
trations of secondary medullary cancers in the same parts. But it
is to be observed that, sometimes, the secondary cancer is medullary,
without osseous matter. I have mentioned three instances of this (p.
646), and Professor Langenbeck told me that he once removed an upper
jaw with a bony growth, and the patient died soon after with well-marked
medullary cancer in the lungs. The reverse may occur : for the same
distinguished surgeon told me that he once removed a humerus with a
medullary cancer, and the patient died with osseous tumors in the lungs.f
The ordinary course of osteoid cancers may be known by the fore-
going account of them, and by the cases recorded by MuUer and Mr.
Stanley.J But deviations from this course are sometimes observed,
which it may be well to illustrate by cases that displayed the disease
in an unusually acute, and an equally unusual inactive, form.
A girl, 15 years old, was admitted into St. Bartholomew's Hospital,
with general feebleness and pains in her limbs, which had existed for
two or three weeks. They had been ascribed to delayed menstruation,
till the pain, becoming more severe^ seemed to be concentrated about
the lower part of the back and the left hip. A hard deep-seated tu-
mor was now felt, connected with the ala of the left ilium. This gra-
dually increased, with constant and more wearing pain ; it extended
towards the pelvic and abdominal cavities ; the patient became rapidly
weaker and thinner ; the left leg swelled ; sloughing ensued over the
right hip ; and thus she died cachectic and exhausted, only 3^ months
from her first notice of the swelling.
A hard lobulated mass was found completely filling the cavity of the
pelvis, and extending across the lower part of the abdominal cavity.
It was firmly connected with the sacrum, both ischia, and the left ilium ;
it held, as in one mass, all the pelvic organs ; and the uterus was so im-
bedded in it, and so infiltrated with a similar material, that it could
scarcely be recognized.
The general surface of this growth was unequal and nodular. It
was composed of a pearly-white and exceedingly hard structure, in
which points of yellow bony substance were imbedded, and which had
the characters of osteoid cancer perfectly marked. The ilium, where
* Cheston, in Philos. Trans., 1780, vol. Ixx.
t A case is reported by Mr. Quain in Brii. Assoc. Med. Jal., Oct. 26, 1855, p. 70. of
osteoid cancer, in which tliere were secondary formations both in the cavities of the thorax
and abdomen. The microscopic appearances are related by Drs. Hillier and Jenner, m
Trans. Path. 8oc., vol. vi, p. 317.
t L. c. See also Gerlach's two cases (1. c), and that by Hunter, in the Cataloj^ue of the
College Musenm, vol. ii, p. 176.
VILLOUS CANCER. 658
the tumor was connected with it, had the same half fibrous and half
bony structure as the tumor itself.
The common iliac veins, their main divisions, and others leading into
them, passed through the tumor, and were all distended with hard sub-
stance like the mass around them. From the common iliac veins a con-
tinuous growth of the same substance extended into the inferior cava,
which, for nearly five inches, was distended and completely obstructed
by a cylindriform mass of similar fibrous and osseous substance, 1^
inches in diameter. At its upper part this mass tapering came to an
end near the liver.
The lower lobe of the right lung was hollowed out into a large sac,
containing greenish pus and traversed by hard coral-like bands, which
proved to be branches of the pulmonary artery plugged with firm white
substance intermingled with softer cancerous matter, and resembling
the great mass of disease in the pelvis. The rest of the lung was
healthy, with the exception of some scattered grayish tubercles ; and
so was the left lung, except in that there were a few small abscesses
near its surface, with hard, bone-like masses in their centres, like those
in the branches of the right pulmonary artery. The skull, brain, peri-
cardium, heart, and all the abdominal organs, were healthy.'*'
I suppose that few cases of osteoid cancer can be found equal with
this in the acuteness of their progress. The opposite extreme is illus-
trated by a case communicated to me by Mr. Thomas Simpson, and ex-
actly corresponding with one of which the specimens are in the Museum
of the College, t A swelling appeared in the upper arm of a woman
82 years old. After ten years* growth, when it had increased to seven
pounds weight, it was removed by Mr. Hewson. It had the characters
of osteoid cancer. The patient completely recovered from the opera-
tion ; but, about a year after it, a new tumor appeared about the hu-
merus, and at the end of four years had acquired a huge size, and a
weight of 15 J pounds. For this, which proved to be a similar osteoid
growth, the arm was amputated at the shoulder-joint. She recovered
from this operation also ; but the disease returned in the scapula, and,
in about 10 years after the amputation, and 24 years from the begin-
ning of the disease, she died.
VILLOUS CANCER.
The name of Villous Cancer (Zottenkrebs of Rokitansky) has been
applied to growths possessing a papillary or villous form, with inter-
spersed cancerous elements, which occasionally project from mucous or
other surfaces. But it is probable that under this name may have been
included growths having the villous character, which in their structure
* The specimens from this case are in the Museum of St. Bartholomew's.
t No. 3244-6-5 a.
were altogether innocent nnd annlogons to the common wsrtB of lh«
akin and denser mucous roenibranea.
Ihe bladder, colon, and rectum appear to he sometimm tbe foU «f
such simple growths, and coses in which, vrith the exutoaoe of nort
decided tIHous structures, the negative evidence agftiutt caoeer wcat
complete, are recorded more especially by Mr. Siblej.* Agun, k
would appear that tbe dendritic growths of a medullary csnctf nay DM
unfrequently assume a villous or papillary character, to tbat thcctfl
elements of this form of cancer may be mingled with projecting rilRt
And, perhaps even more reiidlly, the finely warty ur oftuliBower>Ekc
cylindrlform epithetlal cnncera may take on the villous fomi.} As
though many new ^nllous growths may thus be excluded from tbegrup
of villous cancers, yet there would still appear to be ca»c« to whidi ^
term with advantage may be applied, so that it may be welt not tbo-
getber to discard it. For these cases, then, both for their own ukt,
and for the illustrations they afford of a remarkable mode of grovtk,
which probably prevails throughout a wide range of morbii) stmcton;
a separate description may he given. g
As I have had no opportunity of minutely examining a good nem
* Tnns. Path. Soc., vol. lii, pp. 314, S'>6. Qi*m. apparenlljr of an iunk«n» mhr.ii'
relaied by Mr. Shaw, ib.. Tol. *, p. 900; Mr. H Tbomptun, vol. Tiii, p. 7KI; Mr. hjm.
vol. li, p. 153; HD<1 by Mr. Quain.
t Dr. 6fi)lawe (Tiani. Palb. Sou., vol. li. p. 04) relate* a cue oT camt wT lb* Wil.
in whicb cHnceroua growthi Were minglod with Vltlou* anJ (inpillaiy i>rq)fclkai*.
X In Si. Bnnholomew'i Muwuirt aro fpecimeni of «af h Tillous cancpr* in lb* fll tMI»
(lix, ^) and on tbe ppriionFum (xvi. 60), Sve alio ■ cue bjr Mt. 11. Gray (Tmm. F*
Soc., vol. ri, p. 183) of Tilloui anil epilhclUl ranr«r «( pliaryni and anpbatm,aoimatt
Hi. Sibley (ib. vot. viii, p. IB) of villous growlb un The >lun maief.
{ A very well-marked recent specimen or villous growth bom tbe A«a twfeoxfAt
tnuoouf membrane of the bladder haa been lately shown la die editor hjr U« ft<— d BlI*'
•eph Bell. Within the villi or wbiob ibis growth was composed. cvlMbct**, >a4iriM^
eaneeroui, were inflltrated in large mimbers, to thai tlie speoimen may be iriNtI mmMv
Itnrion of tbe existence of a Torm creancer lo which Ihe lerm vilkiu* may ba«if«b%i^
plied. Throngb Dr. Bell'i kindness bo is enabled in give Ihs Mlowing now of itvafpH*
ancost "About Jibs of Ihe rarrsce oT Ibe miieona coal of the lilaitdar wu tovmivlfcl
growtb which teemed lo consist (when vieweil by ihe nakMl rye) oT ianum*niy> 4mIM
mamcnts mailed together like the pile of B very huio velvet. It was pkto la cafe^lH
ilieakcd wiih a dinky pink and yellow. Examined micraacopicalty, » WMf timd «IP
si«t of slender, Tillmig proceurt growing directly (torn the surlare of ibr muea— — ^t—
itself, and not connected to it by any conslriclad pedicle. These villi vkriad mtttUtttll
in shape, tome being elongated, olhen again mote slunled. From the *t<le«ttr CMM^Alk*
•haped prooFSses projected at intervals, whilst others again bad club«haped •ntMrif^
Some were apparently filled with small, iranspnrenl, dmely-packed sella, wkllM ImoAm
cellii possenqng the ramp cbaracler) were more ijiatin|ily HiMribuieil, amt in (OMaaMiMt
cells were especially arranged aroimd Ihe wide capillary loop situated in Ilia aa«f if *(
villus. From Iha villi the cells could be readily traced into the mu
muoout tissue, which were elotely infiltrated with ihem. In many of tl
nially in tbe larger ones, fat granules, someiimes eollecied into laigo inasH
The oti*e, which presonied several fealutes of inieresi. will shortly be
by Dr. Bell. Tbe speoimen in iis oharaclers very closely rorreepooiled wtl
given by Rokiiansky of the "dendtitio vegetation*' ipiuled in th« trxl.
VILLOUS CANCER. 665
specimen of villous cancer, I will therefore describe their construction
in an abstract of Rokitansky's essay.'*'
The excrescence consists, in its stem, of a fibroid membranous struc-
ture, on which the branches and villous flocculi are borne, as larger and
smaller pouch-like and flask-shaped buddings, or sproutings of a struc-
tureless hollow tissue.
The "dendritic vegetation," of which these sproutings are an ex-
ample, has been already often referred to, especially in the account of
the stroma of medullary cancers (p. 574), which stroma is, indeed, only
another modification of the same plan of growth as the villous cancers
exemplify in a clearer form. Other examples are in the endogenous
growths of cysts ; in the Lipoma arborescens of Miiller, i. e., the tufted
and villous growths on synovial membranes; and in the intracystic
growths of thyroid and other gland-substance, illustrated in Lecture
XXIIL '
.The "dendritic vegetation** appears originally as a hollow club-
shaped or flask-shaped body, consisting of a hyaline structureless
membrane. It is either clear and transparent or opaque, t. e., filled
with granules, nuclei, and nucleated cells (Fig. 97, p. 574) : externally,
it is either bare or covered with epithelium. The vegetation does not
usually develop itself into villous growths directly on the mucous or
other surface on which it rests, but on the bars of some previously
formed meshed-work, such as is described at p. 574. The further de-
velopment of the vegetation is commonly in one of two chief plans.
Either the membranous flask grows uniformly into a sac, which contains
a serous fluid, or is filled with a delicately fibrous meshed-work ; or else
it grows and sprouts in various degrees and methods. Of this sprout-
ing growth, which alone is illustrated in villous cancers, there are three
types. They are represented in the adjoining copy of Rokitansky*s
sketches.
In the first (Fig. Ill, a), the flask grows out in low, nearly hemi-
spherical sprouts. These may contain serous fluid, as in the cystic
disease of the choroid plexuses ; or they may be filled with gland struc-
tures, as in the thyroid and mammary intracystic growths ; or they
may contain and be covered with cancerous structures, as in the in-
stance of the small excrescences within a cyst in a cancerous kidney,
from which Fig. Ill, A, was drawn.
In the second type (Fig. Ill, b) the fiask grows lengthwise into a
tube, and shoots out new ones, which grow to secondary tubes, and
again shoot out others, which grow to tertiary tubes, and so on. On
these outgrowths abundant broader sprouts and buds appear. Thus a
multiformly ramified dendritic structure is produced. Its sprouts may
be filled with connective tissue, or fat (as in Lipoma arborescens), or
with cartilage and bone (as in the pendulous growths of these tissues
* Ueber der Zottenkrebs in the Sitzungsbericbte dcr Kais. Akad, April, 1852.
within joints) ; or ihej may contain And be covered wilh the dflknti
of the cnncer, as in the villoue cancer of the nrinAry bladder, of «bch
part is sketched in Fig. Ill, b.
In the third type, illustrated by Fig. Ill, c, from another tiUbu
Fig. 111."
cancer of the bladder, the flask grows with considerable dilstatioB iuin
a stem, which gives off branches that do not ramify further, but br«^
up at once into a great number of flask-shaped spronU.
The usual arrangement of the bloodvessels of the dendritic njtta-
tions is that (as in the synovial fringea and the villi of the ehoriM) i
vessel runs along the contour of the vegetation, forming
loops, and supplying to the stem, as well afl to each of the >pi
branches, an ascending and a descending vessel. There arc,
pouches in the vegetation in which only a single vessel exiata, aadiv
minates with a rounded end. The vessels are generally largr exHBfbi
of the so-called colossal capillaries, tbiii-walted, with longitudinal, lal
sometimes also transverse, oval nuclei in pellucid mcmbraoe.t
In structure, the vegetation in villous cancers is often hyaline: thil
is, it contains, besides a clear fluid, no tissue-eleraenta ; but it afin
contains, together with its bloodvessels, a quantity of elementary gr»-
Dules, nuclei, and cells, and, especially at the ends of ita spronia, nne-
turelcss, simple, and laminated vesicles. On its exterior, the dawima
of a medullary or melanotic cancer juice adhere to it, oonaiating rf h-
cleated cells of various shapes, which form a soft, or a more monUA
deposit, and are often present in such quantity that they make wpf^
greater part of the morbid mass, into which then the TegctatioM mm
to grow.
In other cases, a fibrous texture develops itself In the interiur if tW
vegetation, and with it cancerous elements form, like those of theeia-
genouB formation just mentioned. In this state the riHoua oanefr, ii
consequence of the accumulation of the fibrous and cancerom Hr•^
tures, appearsasacoUectionof excrescences, which, in their stems as *rfl
L
* Fig. Ill, Mfllhodi of growth or ihv "
nilinl 30 limes: explained in the text.
und ilaa OtlRiid, Taf. i, Fi|t. 3).
Ic TefMiion,' rrom Sokiaatkj. Ht
eipoiKla wilh thii (Drt
VILLOUS CANCER. 657
as in their branches and sprouts, and especially towards their free ends,
are swollen thick and big. They are here filled with a delicately fibril-
lated meshed-work, turgid with medullary cancer juice ; and, as their
swollen ends are often mutually compressed, the whole appears like
foliage growing on shorter or longer stems.
When the villous cancer is cut through to its base, one finds a to-
lerably abundant porous fibrous texture, which, on nearer examination,
presents a compressed meshed-work traversed by fissure-like apertures.
Its bars consist of a hyaline substance beset with oblong nuclei and
nucleus-fibres, and here and there dividing into filaments of connective
tissue. The tissue {e. g. of the mucous membrane) around the base of
the cancer is traversed by a whitish, fine-meshed trellis-work, the bars
of which consist of nucleated cells, and often develop delicate promi-
nences and vesicles, the beginnings of the kind of vegetation from which
the cancer sprang.
The fissured and perforated meshwork in the interior of the base of
the villous cancer corresponds with the stroma of ordinary medullary
cancers (p. 674). Both are constructed on the plan of the dendritic
yegetation. In the construction of the stroma, the sprouting growths
become a meshed-work by partial absorption : in the villi of the villous
cancer they lengthen into branching tubes. And these tubes have, on
the one hand, the import of a stroma, in that the cancerous elementary
structures cover them and fill up the spaces between them, as they do
those between the bars of the more ordinary stroma. But, on the
other hand, the tubes have a nearer and distinctive relation to the can-
cerous elements, in that they produce those elements in their interior ;
80 that there is an endogenous as well as an exogenous production of
cancer-structures. *
In all the instances that have been fully examined, these structures
have been like those of medullary or melanotic cancer. But I believe
Rokitansky is right in the anticipation that certain epithelial cancers
will be found to grow on the same plan as the villous. I have referred
(p. 601) to instances of warty epithelial cancers growing where they
could not have had origin in natural papillae : Virchow also describes
arborescent epithelial cancers growing in cavities where no papilla
could well be ; and I have seen the same in cysts within what I believe
to be an epithelial cancer of the clitoris.f The shapes of the most ex-
uberant epithelial cancers so imitate those of the villous cancers that
it seems highly probable that some of them are produced by the den-
dritic mode of growth rather than by the enlargement and deformity
of papillae.
The correspondence of the stromal structures, and the exact similarity
♦ A description, with illustrative drawing?, of a case of villous cancer of the uterus, is
given by Forster in hin Atlas, pi. 24.
f Museum of St. Bartholomew's, xxxii, 39.
658 COLLOID OAKOBB.
of the cancer-elements, found in the medullary and melanoid cancen
on the one hand, and in the villous cancers on the other, are enough
to warrant us in regarding these as varieties of the more general form.
This view is confirmed by numerous cases in which the central and
basal parts of the growth are like common medullary cancer, its sur-
face being villous ; and by some in which villous cancers appear as se-
condary growths with primary medullary cancers of the more common
kind : thus, e. ^., the former occur on the peritoneum, with the latter
in the ovaries. It may be anticipated that the histories of the villous
cancers will equally coincide with those of the medullary and melano-
tic ; but, as yet, the cases recorded are too few for the deduction of
any general rules.
COLLOID CANCER.
Many names have been given to this form of cancer, — Colloid, Alveo-
lar, Gelatiniform, Cystic, and Gum-Cancer. I have adopted the first,
because it seems to be now most frequently used, and expresses veiy
well the most obvious peculiarity of the diseased structure, the greater
part of which is, usually, a clear flickering or viscid substance, like
soft gelatine.
The most frequent primary seats of colloid cancer are the stomacli,
the intestinal canal, uterus, mammary gland, and peritoneum : as a
secondary disease, it affects most frequently the lymphatic glands and
lungs, and may occur in many other parts.
To the naked eye, a colloid cancer presents two chief constituents :
an opa(iue-white, tough, fibrous-looking tissue, which intersects, parti-
tions, and incloses its mass ; and a clear soft or nearly liquid material,
the proper " colloid** substance. According to the proportions in which
these are combined, the general aspect of the disease varies. When
the fibrous texture is predominant (as I have twice seen it in the cen-
tral parts of colloid cancers of the breast) it forms a very tough, white,
fascia-like mass, in which are small separate cysts or cavities filled
with the colloid substance. In the opposite extreme, large masses of
the colloid substance appear only intersected by fibrous white cords or
thin membranes, arranged as in areolar tissue, or in a wide-meshed
network. These extremes often exist in different parts of the same
mass, and with them are various intermediate forms, in which, probably,
the essential characters of the disease may be best learned. In these,
the cancerous substance appears constructed of small thin-walled cysts,
cells, or alveoli, arranged without apparent order, and filled with the
transparent colloid substance. The cysts or alveoli are, typically, of
round or oval form, but are changed from this, as if by mutual pres-
sure ; some may appear closed, but the great majority communicate
with those around them, through apertures like imperfections in their
walls. They vary from an inch in diameter to a size as small as the
MICROSCOPIC STRUCTURE. 659
naked eye can discern. The largest cysts, and the least abundant
fibrous tissue, are usually at or near the surface of the mass ; and in
these large cysts, when the colloid substance is emptied from them, we
can generally see intersecting bands, or incomplete partitions, as if
they were formed by the fusion of many cysts of smaller size. The
walls of the cysts appear formed of delicate white fibrous tissue, but
cannot be separated from the surrounding substance, and are continu-
ous with the coarser bands or layers of fibrous tissue by which the can-
cerous mass is intersected.
The colloid matter is, in different parts or in different instances,
various in consistence; resembling a thin mucilage, starch-paste, the
vitreous humor, size-gelatine, or a tenacious mucus. In its most nor-
mal state, it is glistening, translucent, and pale yellowish ; but it may
be colorless, or may have a light green, gray, pink, or sanguineous
tint ; and may become opaque, whitish, or buff-colored, by (appa-
rently) a fatty or calcareous degeneration ; or, in the extreme of this
degeneration, may look like tuberculous matter. In water, or in spirit,
it oozes from the alveoli, and floats in light cloudy flocculi ; aud when
the surface of the cancer is exposed by ulceration or by rupture, it is
discharged from the opened alveoli and lies on them like a layer of
mucus.
The colloid cancers have usually, in the first instance, the shape of
the part that they affect ; for they are always, I believe, infiltrations
of the affected part, whose tissues are gradually removed and super-
seded by their growth. But the growth of the colloid cancer enlarges
and surpasses the part in which it is seated, and produces, in such an
organ as the breast or the lymphatic glands, a considerable rounded
and tuberous firm swelling, or, in such a one as the stomach or the
peritoneum, a flattened expanded mass, with more or less of nodular or
tuberous projection.
The extent of growth is sometimes enormous, especially in the peri-
toneum, in which, as in a case related by Dr. Ballard,'*' the greater
part of the parietal and much of the visceral portion may be infiltrated
with the morbid structure, either in a nearly uniform layer, or in nodu-
lated swellings formed of groups of cysts, and sometimes projecting far
into the peritoneal cavity. The cavity itself may, in these cases, con-
tain free colloid matter, discharged, I suppose, from the open superficial
alveoli, and the abdominal walls may be thus distended with a fluctua-
ting vibrating swelling like that of ascites.f
It is not unfrequent to find one or more large and thick-walled cysts
♦ Med.-Chir. Trans., xxxi, 119.
f In Dr. Ballard's case, six quarts of free colloid matter were removed from the peritoneal
cavity after death. I remember an exactly similar case in which, I think, the quantity re-
moved must have been greater, and in which it certainly appeared to be derived from the
debiscence and coutrtant discharge of the alveoli. In the Museum of the College, No. 294,
is 11 mats of peritoneal colloid cancer, from eight to ten inches in its diameters, which was
removed from the lower surface of a liver.
n<:ar or attached to maasea of colloid cancer, and imitating tlie ckane-
tcrs of such proliferous multilocular cysts as arc found in the ortriM.
They are usually filled with colloid matter, and tWr likrncaa to lb*
ovarian cysts may confirm the belief that many of the lattrr arc mBy
colloid cancers of the ovaries.
Moreover, colloid cancer is sometimes found mingled in Um mat
mass with medullary cancer. This ia, indeed, frequeai in th«
canal. Villous and melanotic cancers have been similarly
with it ; and, more frequently, in different part.* of the aai
the medullary and the colloid are found in distinct masses.
Microscopic examination of fragments of colloid cancer
view an arrangement of delicately fibrous and lamellar alnioK
the stroma — imitating, in miniature, the larger appeamnocs vinhltW
the naked eye. Fine lough fbn^
*' or fihreil membranes, are arraa^
in curved bundlea and
which, by their din
interlacements, encircle or
oval or spherical spacM,
ing the colloid 8ub8tsnee.t TW
incloscil spaces are sddo
picte cavitiro ; they comn
freely with one another; a
in their plan, and in the
aspect of the tissue, remii
as Lebert says, of the <itrMt*rs if
a lung, with it
■ir-celk. The fibres are very fine, hut appear stiff and toogh, Mt ■►
dulating nor easily parting ; they are but little and slowly chatifeJ bf
acetic acid. Elongated nuclei are often seated on these fibna. aal
sometimes, Lebert says, elastic fibres are mingled with them. Tkc eat
loid substance fills all their interspaces, — not merely the caritici
they circumscribe, but, as it were, mere crevices between the ■
and spaces in the walls of the larger cavities.
The colloid substance generally appears, however magnified, lif
and structureless; it might be invisible but for the seeming filamcntM
texture produced, as it often is, in spread-out masses, by its fuld* la'
creasingg. Sometimes the colloid material is sprinkled with
dots, like oily or fatly molecules,^ which to the naked eye aaypn
'Fin. lia. Fibnxiaiiuueol'aiwItaidcBnrcroCihebm*). Maentlteil TO Ma*
t Mr Sibley, in a pip«r in the Trnnt. Mnl.-Cbii. Sor., vol. mix, p. SI) I, •■■• Aw A
■noma ofcolloici in iianioiicliNrH(itEri((ierurnia*«iioe»lbe*ha|ie«ra nooTctulaJ — *»—
wlilfh in plaoa ii to tliin Hnd traniparenl, ilmi iu |irnance migUl b* tmitenfcct !•■
oilipt place* w«li-<ieflneil Bbre* maf lie ie*a, wbiiJi brrc ami them eipaail ai ■• M bi ^
linuoui Willi, and eviilvnlty rorm a part of. Ilie niembraDmii iironuu
I Ihil ilieobuivatianaorDr. Jenoer(Pn>R.orPalbol.S(c., IsSt-fla, p. 3U} MtaS^
babic that ihotc uo ti*no\M of v^^^P'***' ^^ '■"■"■
MICROSCOPIC STRUCTURE.
661
it a pecnliarly milky or ochrey aspect ; and sometimes it is beset with
clusters of snch molecules, resulting apparently from the degeneration
of imbedded nuclei or imperfect cells. With these, also, crystals of
the triple phosphate, cholesterine, and some peculiar fatty matter,*
may be mingled.
Lebertf has published au exact analysis of this colloid matter by
Wurtz. The main results are, that it is quite unlike any variety of
gelatine, being insoluble in water, and containing only 7 per cent, of
nitrogen, a peculiarity which distinguishes it as well from all protein-
compounds, and from the materials of which (imperfectly and impurely
as they have been examined), the essential structures of other cancers
are composed.
Imbedded in the colloid substance, but in very uncertain quantity,
are corpuscles of peculiar form. According to Lebert (of whose de-
Bcription and stetches I again gladly avail myself), they are chiefly
these :
(1) Nucleated cells lie free in the colloid substance, or inclosed within
large brood-cells, or grouped like an epithelium on, the boundaries of
the alveoli or cysts. These, the so-called colloid corpuscles, are small,
grannlar, moderately transparent cells, of irregular shape, from tn^gath
to jit'ooth of an inch in diameter, with small nuclei or none. These are,
probably, cancer-cells hindered and modified ia their development by
the peculiar circumstances of their formation ; for, with such as these,
more perfect cancer-cells are sometimes found.
(2) Large compound cells, mother-cells or brood-cells, which in typical
specimens (Fig. 113, a) are from ^Joth to 5 Joth of an inch in diameter,
Fig. 118. J
ate in some instances very numerous. They are very pale, oval, round,
or tubular, and lie in clusters : some of them display a lamellar surface,
indicated by concentric boundary lines; and they inclose one large
granolar nucleus, or several of smaller size imbedded in their general
• Liuchka, in Virchow'a Aichiv, iv,4iy.
t In Virehow'* Arcbiv, iv, 21)3.
t Fig. 1L3. airucinreiof colloid cancer denci
AichiT, B. iv, Taf. v), and Sokiiansky (Uebet d:
From Leberl (Viroliow
662 COLLOID GANOBR.
granular contents, or, together with such nuclei, complete nucleated
cells like cancer-cells.
(8) Large laminated spaces (Fig. 118, b) are also found of nearly
crystalline clearness, from ^^th to jifj^th of an inch in diameter. These
are usually oval and grouped, so as to form a soft parenchyma. Be-
tween the lamellae of their walls elongated nuclei are scattered ; in the
interspaces between them are clusters of small nucleated cells and nu-
clei ; and they inclose brood-cells in the cavities surrounded by their
concentric lamellse.
Whether we consider the larger, or the minuter, characters of this
colloid cancer, it seems difficult to believe that such a structure can
have any close affinity with the cancers I have already described ; they
appear, at first sight, to have scarcely anything in common. Hence,
some have denied altogether the cancerous nature of this disease.*
But if we look, not to its structure alone, but as well to its clinical his-
tory (so far as it is illustrated by the great majority of the recorded
cases), we shall &id in it all tbe distinctive features of the cancers.
Thus (1), its seats of election are, remarkably, those in which the me-
dullary cancers are, at the same time of life, most apt to occur ; (2)
like the typical cancers, the colloid infiltrates, and at length supersedes
and replaces, by substitution, the natural tissues of the affected part;
(3) like them, also, it is prone to extend and repeat itself in lymphatic
glands, the lungs, and other parts near to or distant from its primary
seat;t (4) the colloid is often associated with other forms of cancer in
the same mass, or in different tumors in the same person ; (5) it appears
as apt as any other form to recur after removal ; (6) it may be derived,
hereditarily, from a parent having scirrhous cancer, or a parent with
colloid may have offspring with medullary cancer.
These facts seem enough to prove the right of including the colloid
with the generally received forms of cancer ; certainly they are enough,
if we can explain the peculiarities of the colloid cancer as the result of
any known morbid process in such elemental structures as, in other
conditions, might have been conformed to the ordinary types of cancer.
And such an explanation is not impossible, for, as Rokitansky shows,
the colloid cancer has a near parallel in many cyst-formations in the
normal structures, and especially in those forms of bronchocele in which
* Mr. Sibley especially, from an examination of nine cases, which have fallen under liis
own observRiion, has concluded that colloid is a disease perfectly #ut ^«nm«, and is neither
of a cancerous nature, nor frequently associated with cancer.
f Colloid cancer was thus multiplied in ten out of eleven cases recorded by Leber! In
a ca^e by Dr. Warren (Med.-Chir. Trans., vol. zxvii), the multiplication was to an amount
scarcely surpassed by any medidlary cancers. It is true that it is not unfrequently limited
to the stomach, or rectum and the adjacent lymphatic glands; but this is equally observable
in the ca!^cs of villogs and other* medullary cancers, and I suspect is only an example of a
general rule, that cancers (of whatever kind) on exposed surfaces are, on the whole, more
apt to remain single than those growing in other parta.
RELATIONS TO OTHER CANCERS. 663
abundant cysts, full of viscid fluid, are formed in the growing thyroid
gland. It seems, therefore, a reasonable hypothesis that the peculiari-
ties of the colloid or alveolar cancer are to be ascribed to cystic disease
>occurring in elemental cancer-structures. Such a cystic disease may
ensue in a medullary or other cancer already formed ; but in the well-
marked and uniformly constructed colloid cancer, it is probable that
the deviation to the cystic form ensues in the very earliest period of
the cancer-structures, while each element is yet in the nascent or rudi-
mental state.
Such may be the explanation of the structures of those cancers in
which the formation of cysts is carried to its maximum ; and I have
reserved for this place an account of the various combinations of cysts
with cancers of all kinds, — combinations giving rise to many singulari-
ties of appearance, of which I omitted the description in earlier Lec-
tures, that I might once for all endeavor to explain them.
And first, we may divide these cases into those in which the cysts are
formed independently of the cancer-structures, and those in which they
are, or appear to be, derived from them.
In the first class we may enumerate many cases in which cysts and
eancers are in only accidental proximity. For example, a scirrhous
cancer may occupy part of a mammary gland, in the rest of which are
many cysts that are in no sense cancerous, or of which the chief lacti-
ferous tubes are dilated into pouches or cysts (see page 520). And
such a cancer, in its progress, may inclose these cysts, and they may,
I believe, remain for a time imbedded in it. In like manner, the ovary,
or any other organ, being already the seat of common cysts, may be-
come the seat of cancer ; and the two morbid structures may become
connected though not related.
In this class, also, may be reckoned the cases in which cancers grow
from the walls of common cysts ; i. e., of cysts which did not originate
in cancer-structures. Thus medullary cancers may grow, especially in
the villous form, from the walls of ovarian cysts, which have themselves
no cancerous appearance.*
There may be other methods in which, as by a sort of accident, cysts
and cancers may thus become connected ; but these are the chief exam-
ples. In the second class, including those in which the cysts appear to
be derived from cancer-structures, we find numerous varieties, which
may be studied as a series parallel with those of the simple and the
proliferous cyst-formations in the natural structures, or in innocent
tumors. (Compare Lectures XXII and XXIII, and p. 388.)
(a) Cysts filled with fluid, like serum variously tinted, and in their
general aspect resembling the common serous cysts (p. 359), are often
connected with cancers, especially with those of the medullary form
that grow quickly or to a great size. There may be one or many of
* Museum of St Bartholomew's, xxxi, 20.
664 COLLOID GAHOBB.
such cysts, lying at the sarface, or imbedded in the substance, of the
cancer. Sometimes, a single cyst of the kind enlarges so as to surpass
the bulk of the cancer, exceedingly confusing the diagnosis.* In other
cases so many cysts are formed, that the tumor appears almost wholly
composed of them, the cancerous structure only filling the interstices
between their close-packed walls.f Such cases might justly be grouped
as a ^^ cystic variety" of medullary cancer.
(() Sanguineous cysts are found, as often as the serous, in connection
with the medullary and other cancers ; and the changes which the blood
undergoes in them add not a little to the multiformity of appearances
that the cancerous masses may present.
(c) The colloid cysts here find their type (p. 869) ; not only as con-
structing the peculiar variety of cancer just described, but as being
mingled with ordinary cancerous growths ; for it is common to find with
such growths, especially in the abdomen and pelvis, cysts filled with
thickly-viscid material, like mucus, or half-liquid jelly, in all the varie-
ties of tint that we see in the cystic disease of the kidney or of the
thyroid gland.
{d) While thus the principal varieties of simple or barren cysts are
found in cancerous growths, as in the original tissues, or in simple
tumors, so may we also trace in them the production of proliferous
cysts ; t. e. of cysts from whose inner surfaces cancerous growths arise,
corresponding with the glandular growths that may fill the cysts in the
mammary or thyroid gland (p. 879). I have already often referred to
this (pp. 389, 563, &c.) ; and now, need only add that such endogenous
growths are often to be found in the alveoli of the colloid cancer. Clus-
ters of clavate, or flask-shaped villous processes, like those formed in
the early stages of the dendritic vegetation of villous cancer (p. 655),
spring from the wall of the alveolus. With laminated walls, and can-
cer-structures, or new cysts in their cavities, such villous growths
crowded together probably constitute the structures which I have de-
scribed after Lebcrt (p. 661, Fig. 113, c).J To less perfect endogenous
growth wc must, I suppose, ascribe the cancer-structures which are
found disorderly mingled with the colloid contents of the alveoli.
Thus is the general anatomy of the autogenous cysts, which I de-
scribed in Lectures XXII and XXIII, paralleled in the cysts con-
nected with cancers. It may sufiice to add that Rokitansky has traced
a similar correspondence in their origin and modes of development.
The account of the formation of cysts (p. 355, e. s.) might therefore be
again read here ; with the understanding that the nucleus, or smaller
corpuscle, by whose enormous growth a cyst is formed, is here a cancer-
ous clement, while, in the cases there cited, it was supposed to be an
* Brnch (Die Diagnose der Bosartigen Geschwulste, p. 1): Mus. Coll. Surg., 281.
t Mns. Coll. Surg., 277, 279, 280, &c. ; Miis. St. Bartholomew's, xxxv, 14, and others.
X Compare Lebert's figures with those of Rokitansky (Ueber die Cyste, pi. iv, fig. 16).
FIBROUS CANCER. 665
element of some natural tissue. A part of the process is, moreover,
already exemplified in the instance of epithelial cancers (p. 618, Figs.
104-5) ; but in these, the cysts, produced in the shape of laminated
capsules, are very rarely barren, or filled with colloid substance.
Respecting the history of colloid cancer, the number of well-recorded
cases, especially of those in which external parts were its primary seat,
is too small to authorize many general statements.
Lebert has shown, by his collection of cases, that it generally cor-
responds with the history of scirrhous and medullary cancers ; that the
cases are about equal in the two sexes ; that the greatest absolute fre-
quency is at the middle period of life; that the disease is very rare in
childhood;* that it is probably of somewhat slower average progress than
the medullary cancers ; that it more slowly afi*ects the lymphatics and
the organs distant from its primary scat ; that, in general, its symptoms
in each part correspond with those of other cancers affecting the same
part : and this summary, I believe, includes all that can be prudently
said upon the matter.
FIBROUS CANCER.
Among the Cancers it may, perhaps, be as well to arrange those
tumors which, in the former edition^ I classed by the name of Malig-
nant Fibrous Tumors, with the Fibrous Tumors. For although in their
structure they do not contain those cell-forms which we are in the habit
of regarding as especially cancerous or malignant, yet in their tendency
to recur, and to produce secondary formations of a similar structure in
internal organs, and in the infiuence which they evidently exercise in
shortening the lives of those in whom they occur, they present so many
malignant features, that they seem to fall more naturally into this
rather than the innocent class of tumors. For although in the very
large majority of cases the structures of cancers are unlike those of the
normal textures of the body, yet there are instances in which tumors,
eminently cancerous or malignant in history and habits, approach or
even attain to, close similarity to the natural tissues. And here I might
repeat what has already been stated in the lecture on recurrent tumors,
that in studying the histories of tumors it is not sufficient to content
one's self with a mere determination of their structure. The " life** of
tumors is, in some respects, at least for the present, a better basis for
classification even than their structure.
One of the best marked cases in which a tumor, presenting the usual
characters of a fibrous tumor, not only recurred after removal, but even
formed secondary tumors of a like nature in internal organs, occurred
* He adduces two cases of cbildrerif in which one was 2, the other J } years old. Mr.
Edward Bickersteth has observed two cases of colloid cancer of the kidney in children, one
of whom was 3}, the other 11, years old.
43
in a poor widow who was under mj care several years agoi. Ska n»
47 years olil, and had been crippled wilh acnle rbeutnatiMii fur tct
years before she found a small movable tumor in her right lirrait
This had increased slowly till seven weeks before I saw her, wh^n, hav-
ing been struck, it began to grow very rapidly, and became the »nl
uid centre of severe pain. It increased to between two and thrt* incbri
in diameter, was nearly spherical, very firm, tense, and painful,— cm
eitremely painful. I supposed it to be a large hard cancer, aii<i >«-
moved the whole breast. I found the tumor completely separabU fro*
the mammary glund, which was pushed aside by it, but wa> IimUIit;
the cut surface could not, I think, have been distinguished fram tlai
of an ordinary fibrous lumor of the uterus, witb nndulatdl whitetoiuk
excepting that piirt of it had a suffused purplish tinge.* The ■hai<
substance of the tumor had the same characters ; and in microwqM
examination, often and lately repeated. I could End nothing but too^
compact, well-formed fibrous tissue, wilh imbedded elongated nuclei.
On boiling, gelatine was freely yielded. In short, I believe it vwld
be impossible to distinguish, by any means but the history, this tnma
from a common unmixed fibrous tumor of the juw or subcntaaeow
tissue.
Three months after the operation a tumor appeared under the mr.
It grew very quickly, and felt just like the former tnmnr. AfWt iw
months the thin scikr began to ulcerate, and the integumenu tnml
sloughed ; and shortly the whole of this tumor was separated by tkn^
ing, and was removed entire. This also had. and, in the Mnteatf
St. Bartholomew's, still retains every character of the comaon tUtnm
tumor.
After the separation of this second tumor, a huge c«vitj
with sloughing walls; then, as the sloughs cleareil away, hard ki
like those of a cancerous ulcer, grew up from the walls, and the <!!■
assumed all the characters of a vast and deep bard rsnc«roas >or*.
two months she died. I found the ulcer nearly a foot in dianHer
walls were formed of a thick nodulated layer of hard, whitish, nte
substance, like the finnest kinds of medullary cancer. Both iatp
tained between twenty and thirty small masses of similar
imbedded or infiltrated in their tissue;'}' and this substance I hsvtr^
cently again examined, and found to be a complete fibrous tisrar, Eb
that of the first tumor removed. I found no similar disease elsewkat
All the characteristic features of malignant disease were thus sllf(^
added to the growth of a tumor which appeared to be, in every ttrvuni
character, identical with the common innocent fibrous tumor. SaPj
the same events were observed in the following case : In IBSS, t w^
ii is ibe MnHum of St, Biidiolontaw'*, Sat. ixxiv, Ka,a4i mi4'*
m College Museum. No. 333.
f Mua. Sl Banholoinew'a, Ser, liv, No. 4!) ) Hut. OolL Surt, 23«.
HALIONAKT TUMORS.
667
Fig. 114.»
was in St. Bartholomew's Eoepital, under the care of Mr. Earle, with
a large spheroidal tumor, lying by the base of bis scapula, and extend-
ing beneath it. It was removed ; and I remember that it was easily
enncleated from the adjacent parts, and was called " albuminous sar-
coma;" but it was not preserved. About a year afterwards the man
returned with a yet larger tumor in the same situation. Mr. Skey re-
moved this, together with a large portion of the scapula, to both surfaces
of which it was closely united. The wound was scarcely healed, when
another tumor appeared, and increased rapidly. With this the patient
died, and growths of simiUr substance, white, very
firm, and nodulated, were Found beneath that part of
the pleura which corresponded with the growth on the
exterior of the chest. I state these particulars from
memory ; but I have found, from repeated recent ex- i
aminations, that the tumor removed by Mr. Skey is of r
fibrous texture, resembling the common fibrous tumors
both in general and in microscopic characters, and,
like them, yielding gelatine when boiled. f It is lobed,
with partitions of connective tissue, and its several
lobes are intersected with obscure opaque-white fibres :
it is tough, compact, and heavy, and tears with an
obscure fibrous grain. It is easily dissected for the
microscope, tearing into fasciculi, and appears com-
posed wholly of closely-placed and nearly parallel un-
dulating filaments. A few shrivelled nuclei appear
among the fibres, but no cells are distinguishable.
Its structure is represented in Fig. 114.
To these cases I may add, though it be an imper-
fect one, that of a woman from whose back Mr. Law-
rence removed a large well-marked fibrous tumor,
which had grown nine months after one of the same appearance had
been removed from the same part.| Before removal, this was judged
hy all who saw it to be malignant ; hut it presented a genuine fibrous
Btructure, and could not, I think, be distinguished from an ordinary
fibrous tumor. ^
Such are the cases which make me believe that tumors occur, resem-
bling in all respects of structure and chemical composition the fibrous
tumors of the uterus (excepting their muscular fibres), or of the bones
* Fig. 114. Tisnia of a matignanl flbrouslumororilie Bcapula: desctibeil nbove. Mag-
Di£ed about 400 time*.
t Ilia in IheMuKumofSl. Bar ibolo mew's, Series xiiv, No. &1. A limilaT cose by Mr.
J. Z. Lawnoce, Diagnous of Surgical Cancer, p, 73, Tbis caae is also deactibed by Mi.
Sible]', along with leveral olheit (Fath. Traai., vol. viii, p.' 3J0), as a tnuhiple fibrous lumor.
He fullf reci^izea Ihe relations, both as regards structure and progress, to tiie tumors de-
■cribed in the leit, but hs pronounces against theii cancerous nature, and thinks that they
h*TS close analogieti io Ihe recurring fibroid tumois.
% Htu. St. Banholoniew'a, Ser. xxiv, 52.
668 GENERAL PATHOLOGY 07 CANCER.
or subentanoous tissue, yet differing from these in that they ponnie a
course like that of cancers, recurring after removal, growing at the
same time in internal organs, tending to sloughing or ulceration, and
in the latter process involving adjacent structures. I have related only
cases in which the fibrous structure was proved by microscopic exami-
nation ; but I have little doubt that others might be added from cases
of tumors of the jaws and other bones, which have been believed, from
their general appearance, to be fibrous, yet have pursued a malignant
course. I will only add that these are not such growths as those which
Miiller and others have named Carcinoma fibrosum (described p. 580),
and of which, I believe, that they are always infiltrations in the substance
of the affected organs, and they generally include cancer»cells with
their fibrous tissue, and that they have in this tissue such hardness,
stiffness, and other peculiarities of structure, as make it easily distin-
guishable from the normal fibrous tissue and its imitation in the fibrous
tumors.
LECTURE XXXIV.
GENERAL PATHOLOGY OF CANCER.
PART I.
CONDITIONS PRECEDING THE CANCEROUS GROWTH.
I PROPOSE, in this and the next Lecture, to consider the general
pathology of all the forms of cancer which have now been particularly
described ; to gather a general history of them from the statements
made concerning each ; and to trace how the laws observed by them
correspond with the more comprehensive laws of all specific diseases.
I have stated on page 347 the hypothesis which I think we must
hold concerning cancers : namely, that they are local manifestations of
certain specific morbid states of the blood ; and that in them are incor-
porated peculiar morbid materials which accumulate in the blood, and
which their growth may tend to increase.
In the terms which are more usual in discussions respecting the nature
of cancers, I would say that a cancer is, from the first, both a constitu-
tional and a specific disease. I believe it to be constitutional, in the
sense of having its origin and chief support in the blood, by which the
constitution of the whole body is maintained ; and I believe it to be
specific, Ist, in the sense of its being dependent on some specific ma-
terial, which is diiferent from all the natural constituents of the body,
and difierent from all the materials formed in other processes of disease;
and 2dly, in the sense of its presenting, in the large majority of cases,
CONDITIONS PRECBDINQ CANCEROUS GROWTHS. 669
structures which are specific or peculiar, both in their form and in their
mode of life.
The evidences for this hypothesis appear in the conformity of cancer
to the other specific diseases, for which a similar hypothesis is nearly
proved (Lect. XX), and in the fitness of the terms' which it supplies for
the general pathology of cancer.
I will speak in this lecture of the conditions that precede the forma-
tion of a cancerous growth, and in the next of the growth itself.
The general history of cancers, and their analogy with other diseases
that are, in the same senses, specific and constitutional, imply that,
before the formation of a cancerous growth, two things at least must
coexist: namely, a certain morbid material in the blood, and some
part appropriate to be the seat of a growth incorporating that material,
some place in which the morbid material may assume, or enter into, or-
ganic structure.
The existence of the morbid material in the blood, whether in the
rudimental or in the effective state, constitutes the general predisposi-
tion to cancer ; it is that which is by some called the predisposing
cause of cancer. The morbid material is the essential constituent of
the "cancerous diathesis or constitution :*' and when its existence pro-
duces some manifest impairment of the general health, independently
of the cancerous growth, it makes the primary cancerous cachexia (see
p. 553).
That which evidently makes some part of the Body appropriate for
the growth of a cancerous tumor is a so-called exciting cause of cancer ;
but it is a cause of cancer only in so far a^ it fits some part for the local
manifestation of u disease which already, in its essential material, exists
in the blood.
It seems very important to keep constantly in view that these two
conditions must coincide before the appearance of a cancerous growth ;
important not only to recognize their existence, but, if we can, to
measure the several degrees in which, in each case, they are present ;
because, upon our recognition of the shares in which they respectively
contribute to the production of the cancerous tumor, must depend the
chief principles of practice in relation to the removal of such tumors.
The larger the share taken by the constitutional element of the dis-
ease,— that is, by the cancerous condition of the blood, — in the pro-
duction of a cancerous growth, the less is the probability of advantage
to be derived from the removal of that growth ; while, on the other
hand, the more largely the local state enters into the conditions upon
which the cancerous growth is founded, the more benefit may we antici-
pate from the removal of the cancer and of the locality with it.
So, too, in our considerations of the mere pathology of cancerous
diseases, it seems essential to have a just regard of both these previous
conditions. If we look at only a certain class of cases, we may easily
find enough to persuade ourselves that cancers are, from the first, and
670 QBNBRAL PATHOLOQT OF GANOBB.
throughout their course, wholly constitutional diseases; or, if we look
exclusively at another class, which are as truly cancerous aa the first
(according to any natural definition of the term), we may find equal
evidence for believing that they are, at least in the first instance, esh
tirely local diseases, and that the constitutional afiection which may
attend them is only something consequent upon their growth.
When, for example, we see that certain organs are much more liable
than others to the growth of cancer, and that, in those organs, the
growth sometimes follows the infliction of a local injury or some pre-
vious disease ; and much more when we see, as in the case of the scro-
tal epithelial cancers, that the repeated application of a stimulus sudi
as soot, to a part of the body, will lead to the formation of cancer in
even a large number of persons, we might assume that the growth has
its origin wholly in the local state, and that whatever may follow of dis-
ease in other parts is only the consequence of the growth. On the
other hand, when we consider the numerous analogies between cancers
and the admitted specific blood-diseases ; when we see the rapidity of
outbreak with which cancerous disease sometimes manifests itself in
multiple growths, apparently irrespective of the locality in which they
are produced, and how sometimes a distinct affection of the genenl
health, intense and destructive, exists even while the cancerous stmo-
ture is yet trivial or unobserved ; and when we see the insufficiency of
all local causes to excite the growth of cancer in some persons, we might
suppose that the cancerous disease is one wholly constitutional, wholly
dependent on some morbid condition of the blood, and that the forma-
tion of the tumor is but as an accident of the disease, and is independent
of the state of the part in which it occurs.
It is in correspondence with these classes of cases, too partially ex-
amined, that two distinct opinions are commonly entertained respecting
the nature of cancer : some holding that it is from the beginning, and
throughout, a constitutional disease ; and others, that it is, in the first
instance, if not through its whole course, a local one. The reconcilia-
tion, not only of the two conflicting opinions, but of the seemingly con-
flicting facts upon which they chiefly rest, is to be found in this, — that
the complete manifestation of cancer — the formation of a canceroos
growth — is suspended till such a time as finds both the constitutional
and the local conditions coexistent, — till the blood and the part are at
once appropriate.
I might show how consistent the belief of the necessity of this coin-
cidence is with what is known of other specific diseases. But let me
illustrate it by two cases, such as may frequently be met with. Bruch*
records the following : A woman had a child at eighteen years of age.
The child died when it was a month old, and her breasts were left to
the disturbance which usually ensues in prematurely arrested lactation.
* Die Diagnose der bOsartigen GesohwQUte, p. 94.
GENERAL PATHOLOGY OF CANCER. 671
At the age of thirty-four she received a blow on the right breast. This
was followed by no manifest change of structure, but, for some days,
by severe pains, and then, for a much longer time, by feelings of swell-
ing and tension at the menstrual periods. At thirty-nine she received
another blow upon the same breast, which was followed by an increase
of pain. Soon afterwards she was exposed to cold, and then there en-
sued erysipelatous inflammation of the breast, followed by induration
of the part of the mammary gland. This, however, continued without
change for four years ; but then, after menorrhagia, a tumor appeared
in the breast. When this was removed, or partially removed, it was
found to be not a cancerous, but a cystic tumor, with growths from the
interior surfaces of the cysts. She remained well after this, the wound
having perfectly healed, for twelve years more, and in this interval she
ceased to menstruate ; but now, when she was fifty-five years old, after
having a whitlow and inflamed lymphatics of the right arm, another
tumor formed in the breast, which had every appearance of being can-
cerous. It was removed ; but it recurred, and ended fatally.
Now, surely, in such a case as this, we may say that all the local
conditions necessary for the production of a cancer of the breast had
been amply provided. They had existed, or had been reproduced from
time to time, for a period of upwards of twenty years ; yet being alone,
they had been insufficient ; and no cancer appeared till the time when,
at a more favorable condition of age, the cancerous condition of the
blood was manifested, and filled up the measure of the necessary pre-
cedents of the disease. ^
Contrast with the cases of this kind those to which I had occasion to
refer in a former lecture (p. 584), and of which I may here repeat one :
A boy received a cut in his eye, which had been previously sound.
Within three weeks of the injury a fungus protruded from the eye. It
was removed with the whole eyeball and the contents of the orbit. The
wound had scarcely healed before a fresh growth appeared ; and shortly
afterwards the boy died with medullary disease extending from the
orbit to the brain. We can scarcely express such cases as this in any
other terms than that the cancerous condition of the blood existed at
the time of the injury, but was insufficient for the production of a can-
cerous growth, and remained latent, for want of an appropriate locality
for the growth, till the injury, disturbing or causing the suspension of
the natural course of nutrition in the part, supplied the appropriate
local condition. As one might say, the seed had been long present in
the blood, but the soil was wanting, and the injury, hindering or divert-
ing the eye from its ordinary nutrition, supplied the want, and prepared
the soil for the growth of the cancer.
These cases, I repeat, are but examples of classes. In the one class
we seem to meet with all the constitutional or blood-conditions of can-
cerous disease complete, waiting only for the existence of some part in
which the cancerous growth may be manifested ; in the other class, the
672 LOCAL AND CONSTITUTIONAL PREDISPOSITIONS.
local conditions are abundantly present, but the disease does not appear
till the cancerous condition of the blood is complete (compare p. 332).
It may, further, be deduced from these cases, in which the extremes
illustrate the ordinary mean, that if either of the two conditions be
present in an extreme degree, its intensity may compensate for a com-
parative defect of the other. Among the cases to which I have been
referring, we find certain in which the cancerous disease makes its ap-
pearance in such a multiplicity of growths and of parts, that it seems
indifierent to local conditions ; and these are the very cases in which
all the other constitutional characters of cancer are most strongly
marked ; in which cachexia often precedes the growth, and in which
the removal of the cancer interferes in no way with the progress of the
constitutional disease, unless it be to accelerate it. On the other side,
we meet with cases in which the long-continued irritations, or frequent
injuries of certain parts of the body, seem almost sure to be followed
by cancer ; and these are the cases in which the constitutional charac-
teristics of the disease are least marked, and in which, as in epithelial
cancer of the scrotum and of scars, we may hope that the recurrence
of the disease may be long deferred, if that which has first appeared be
removed with its seat. In this class of cases, it may be said, the can-
cerous blood-condition is so lowly developed, that the cancerous growth
can ensue in none but a peculiarly appropriated part, which part being
removed, the growth is for a time, or for life, impossible ; while, in the
former class, the blood-condition is so highly developed, or so intense,
that almost any part suffices for the seat of growth.
Let me now proceed to consider what each of these conditions, ne-
cessary as precedents of the growth of a cancer, consists in. What is
the cancerous condition of the blood ? and what is the state of a locality
apt for the formation of a cancerous growth ?
I. Concerning the state of the blood, our positive knowledge is very
trivial and obscure ; perhaps it would be safest to say that we have at
present none. We may be sure, on grounds to which I have already
referred, that there is a peculiar material in the blood which is separated
from it, and constantly renewed, in the formation of a cancer ; but we
can say what this material is not, rather than what it is.
We may reasonably hold that, in cancerous persons, the whole con-
stitution of the blood is not perverted ; for we see that all the tissues
may for a long time be perfectly nourished, even while the cancer is
making progress; that injuries may be repaired with the ordinary quick-
ness and perfection ; that the products of inflammation may be like
those in non-cancerous persons, and may pass through their ordinary
developments ; and that some other specific diseases may have their
usual course. It would therefore be unreasonable to rcixard the whole
of the blood of a cancerous person as perverted from its normal con-
dition. The cancerous state is not a total change of the blood, but de-
GENERAL PATHOLOGY OP CANCER. 673
pends, probably, on some definite material mingled with the natural
constituents : and this material, we may believe, is derived from a mor-
^bid transformation of one or more of the natural constituents of the
blood, and is maintained, as morbid structures are, by the persistence
of the same method of transformation, or by its own assimilating force.
But now, as to what this material is ; or, again, is not. I believe it
is not anything visible to the sight. There is not, so far as I know,
anything in the blood of a cancerous person which we can recognize as
a cancer-structure. There are no cancer-cells, nor, in any form, visible
germs of cancer, existing in the blood, and only needing to be separated
from it to make up or grow into the cancerous structure. In advanced
cases of cancer, and especially in those in which the cancerous substance
is very softened and broken, we may meet with portions of it in the
blood, which appear as if they had been detached or absorbed from some
growth, and carried on with the stream. In similar cases we may find
cancerous formations in the blood itself. Such seem to be some of the
cancerous growths in the veins and the right side of the heart. For,
although among the former there are many in which the growth has
only extended into the veins, through their walls involved in cancerous
tumors, yet there are others in which, as in the endocardial cancers, the
internal growth takes place far from any other tumor. In these we
may believe that cancerous structures have been conveyed in the blood
to the part of the vein, or of the right side of the heart, at which they
have been arrested, and to which adhering (either alone or with blood-
clot), they have subsisted and grown on materials derived from the
passing blood. But not one of these cases affords any support to a
belief that, previous to the existence of a cancerous tumor, any visible
germs of cancer exist in the blood.
Other means for investigating the very nature of the cancerous mate-
rial in the blood seem as important as the sight. Minute chemistry
has, up to this time, done nothing; neither can we accept, I think, that
w^hich is in part a chemical theory, and has been especially held by the
pathologists of the Vienna school, — namely, that particular diatheses
or dyscrases of the blood appropriate to such diseases as cancer and
tubercle, may be recognized by a superabundance of albumen or of
fibrine. The facts adduced as bearing directly on these doctrines are,
at present, few and incomplete ; and I think they are not suflScient
either to establish the theories based on them, or to outweigh the gene-
ral probability that diseases so complex as cancer and tubercle should
depend chiefly on quantitative variations in any of the larger constitu-
ents of the blood. Neither can it, I think, in the present state of or-
ganic chemistry, and with so few analyses as we yet possess of the blood
of cancerous and other diseased persons, be more than a guess, that
either cancer or any other such specific disease, depends, in any sense,
on qualitative modifications of the albumen, or the fibrine, or any other
single constituent of the blood.
674 INCOMPATIBLB BIBBASBS.
At present, I believe, the best part of the facts established, or nude
probable, by these investigations, relate to the antagonism or ineom-
patibility of cancer and certain other specific diseases. I think we can-
not doubt that, as a general rule, cancerous and tuberculons diseases do
not make active progress at the same time ; and that, in this sense,
they exclude one another, and are incompatible. I mentioned in a
former Lecture (p. 549), a striking case bearing on this point, in which,
as it seemed, the rare event of arrest and almost complete recovery
from scirrhous cancer was connected with the evolution of tuberculous
disease. I believe, also, that I have seen at least one instance in which
active tuberculous disease of the lungs was arrested immediately before
the appearance of a scirrhous cancer in the breast : and we find, in so
many of those who die with cancer, the remnants of tuberculous dis-
ease from which they have suffered in earlier life, that we may believe
that the recovery from the one has been in some manner connected with
the supervention of the other. So, on the other side, the rarity of pro>
gressive tuberculous disease in those that are cancerous may be because,
except in such extremely rare cases as that to which I have referred,
the cancerous diathesis excludes that condition of the blood in which
the tuberculous disease has its rise.
To the same class of facts, as illustrating the exclusion of one morbid
condition of the blood (or, as Hunter would have said, of one morbid
action), by another, we may perhaps refer the occasional withering of a
cancer under the influence of some fever, and the more rarely occur-
ring complete death of one, so that during an attack of acute fever the
whole mass may slough off; and this whether the feverish condition of
the blood be produced by some miasma, or by medicinal means. Such,
I fear, is all that can be at present safely regarded as matter of fact
in relation to the nature of the peculiarity of cancerous blood ; aud it
must be admitted that those facts are scarcely more than indications of
the direction in which inquiry should be made. Let us next see if we
can in any measure trace the method of its production ; — whence the
specific material is derived from without, and the conditions most favor-
able to its generation within, the body.
First, it is evident that a disposition to cancer may be derived by
inheritance ; that something may be transmitted from the parent to the
offspring, which shall utimately produce both the cancerous condition
of the blood and the locality apt for the cancerous growth.
In 322 cancerous patients, there were 78, or very nearly one-fourth,
who were aware of cancer in other members of their families. The
proportion is much larger than could be due to chance ; and its import
is corroborated by the fact of many members of the same family being
in some instances affected.*
That which is transmitted from parent to offspring is not, strictly
* Medico-Chir. Trans., vol. xlv., op. cit.
GENERAL PATHOLOGY OF CANCER. 675
speaking, cancer or cancerous material, but a tendency to the produc-
tion of those conditions which will, finally, manifest themselves in a
cancerous growth. There are here some facts worth dwelling upon,
both for their own sake, and because they are clear instances of the
manner in which the hereditary transmission of the properties of the
parent body takes place.
I repeat, that which is transmitted from parent to ofispring is not
cancer itself, but a tendency to the production of cancer at some time
far fature from the birth. We have no reason to believe that a cancer-
ous material passes with the germ. To suppose such a thing, where the
cancerous parent is the male, would be almost absurd. Moreover, no
reason to believe that cancerous material passes from either parent is
furnished by any frequency of congenital cancer.
But while, on the one hand, we cannot assume that a cancerous mate-
rial passes with the germ or impregnating fluid ; on the other, we can-
not understand the transmission of a tendency or disposition to any
event, independently of all material conditions. The germ from the
cancerous parent must be already, in some condition, different from one
from a parent who is not cancerous, if, in the course of any number of
years, cancers are to be formed out of the substance which the germ, in
its development, or subsequent changes, will appropriate. Our ex-
pression, then, may be, that in the impregnated germ from a cancerous
parent, one or more of the materials, normal as they may seem, are
already so far from the perfectly normal state, that after the lapse of
years, by their development or degeneration, they will engender or
constitute the cancerous material in the blood, and, it may be, the
locality apt for a cancerous growth.
But now let it be observed, this tendency to cancerous disease is
most commonly derived from a parent who is not yet manifestly can-
cerous ; for, most commonly, the children are bom, and sometimes even
become cancerous before cancer is evident in the parent ; so that, as
we may say, that which is still future to the parent is transmitted po-
tentially to the offspring. Nay, more : the tendency which exists in
the parent may never become in him or her effective, although it may
become effective in the offspring ; for there are cases in which a grand-
parent has been cancerous, and although his or her children have not
been so, the grandchildren have been. How admirable a discovery it
would be if we could find the means by which the tendency, conveyed
from the grandparent to the child, was yet diverted from its course, *
even after it had been transmitted to the germ of the grandchild !
Let me repeat, the cases of hereditary cancer only illustrate the com-
mon rule of the transmission of hereditary properties, whether natural
or morbid. Just as the parent, in the perfection of maturity, trans-
mits to the offspring those conditions, in germ and rudimental sub-
stance, which shall be changed into the exact imitation of the parent'^s
self, not only in the fulness of health but in all the infirmities of yet
676 HBRBDITABT TRANSMISSION.
future age ; so, also even in seeming health, the same parent may com-
mtinicate to the materials of the offspring the rudiments of yet future
diseases; and these rudiments must, in the case before us, be such
modifications of natural compositions as, in the course of many yean,
shall be developed or degenerate into materials that will manifest them-
selves in the production of cancer.
There is, surely, in all science, no fact so strange as this : and it
need not be a barren fact, fit merely for wonder and vain speculation ;
for we may deduce from it that the cancerous substance in the blood,
whatever it may be, and whencesoever derived, is a result of long-con-
tinued elaboration ; needing, as the normal materials of the body do, to
pass through a life of continual change before it attains its complete
efficiency. The period required for this completion of the cancer-ma>
terial, is the time often of long delay, during which the disease, accord-
ing to various expressions, is 'Matent," or only in '^predisposition."
But such expressions are deceptive. As with other specific blood-dis-
eases, so with cancer, the predisposition to it is a substantial thing ;
and we should hold that, in all the time of latency, there is that thing
in the blood which will become, or generate by combination, the effec-
tive cancer-material, unless (as in the healthy generation between the
cancerous grandparent and the cancerous grandchild) it be destroyed
or retained in the course of natural nutrition.
In hereditary transmission, the cancer-material may be modified, so
that the form of the disease in the offspring may be different from that
in the parent. The change from scirrhous to medullary cancer, and
vice versa, is, I believe, not rare. I have mentioned cases of alterna-
tion between these and the epithelial cancers (p. 626) ; and a case of
melanoid cancer in a patient descended from one with a scirrhous breast
(p. 641). Mr. Simon has told me that he removed a colloid cancer
from the check of a woman, whose child, seven years old, was dying
with medullary cancer of the eye ; and M. Lebert, with two cases like
these, relates that the celebrated Broussais died with medullary cancer
of the rectum, and his son, Casimir, with colloid cancer of the same
part. With so many cases supporting it, this kind of transmutation
during transmission of cancer, can hardly be doubted. But I believe
we may trace further changes in the transmission ; and that the ma-
terial may be so altered that, as we may say, the cancerous disposition
may gradually cease, or fade out in the production of tumors, whose
characters are intermediate or transitional between cancerous and sim-
ple growths. I have referred (p. 491) to cases illustrating this opi-
nion ; and I feel sure that many more will be found ; for we may
observe corresponding changes in both form and degree, in the here-
ditary transmission of many other diseases. Thus the syphilis of the
infant is seldom exactly like that of the mother ; the same family may
include cases of insanity, epilepsy, palsy, chorea, stammering, and
.GENERAL PATHOLOGY OF CANCER. 677
other diseases allied to these in all that are affections of the nervous
centres, but differing from them in form and degree.*
The rule of hereditary transmission (a rule which, like many in patho-
logy, has more seeming exceptions than examples (p. 326), holds for
only a fourth of the cases of cancer. Can we, for the remaining three-
fourths, trace any external source of the morbid condition of the blood ?
Inoculation and contagion are the only probable sources of the kind ;
but concerning these the presumed facts are, at present, very few and
uncertain. There are cases in which, by the inoculation of cancerous
material into the bodies, or by the injection of such material into the
blood of dogs, cancer has seemed to be produced. I think that, in a
large number of experiments, that result has been three times obtained ;
but it is quite possible that the dogs used for these three experiments
were cancerous before the human cancerous matter was injected into
them ; for cancer is indeed a frequent disease among dogs. The in-
stances are certainly too few for proof of inoculation.
There are, also, certain cases in which it seems possible that cancer
may have been transmitted from the wife to the husband during the
act of copulation. Such cases are recorded by Dr. Watson and Dr.
Copland rf wives having cancer of the uterus had husbands with cancer
of the penis. Of course it must be questionable whether there were in
these cases more than the accidental coincidence of persons having mar-
ried, in both of whom an ordinary and independent generation of cancer
ensued ; and we cannot conclude that inoculation of cancer may thus
occur, unless it should appear that persons thus related become cancer-
ous in larger proportions than they do who, being otherwise in similar
conditions, are not thus exposed to the possibility of inoculation.
Again, I have heard that cancerous matter having been inoculated
under the skin of frogs, cancerous growths have been produced in them.
I have repeated this experiment, but without effect ; for all the frogs
in whom I inserted the cancerous matter died soon after. But the facts,
80 far as I have yet heard them, have not much meaning in relation to
the general pathology of cancer; for I believe it is not yet proved that
the local growths of cancer, which are the consequences of the inocu-
lation, are followed by general cancerous disease, or by the production
of cancer in distant parts, as well as in that in which the matter was
deposited. Unless this occurs, the experiments only prove the fact
(and a very strange one it is) that materials of disease from human
bodies, being inserted in the bodies of cold-blooded animals, will live
and grow, even upon the materials of the cold-blooded creature. In
like manner, if any one could establish the supposed cases of husbands
inoculated by their wives, he might only prove that cancerous elements
* Hereditary malformations display similar mutations m trantitu ; as in instances in the
Mosenm of St. Bartholomew's, Casts A 21 to 27. The whole of this subject of the change of
diathesis in hereditary transmissions will repay, I believe, the deepest study.
t Diet of Pract Med. ; Art. Scirrhous and other Tumors.
678 INFLUENCE OF AGE.
may subsist and increase upon other materials than those of the body
in which themselves were generated. Unless the cancers thus gene-
rated, in the first instance locally, are found to multiply themselves in
distant organs, these cases of inoculation will prove no more than that
cancer, like a parasitic growth, may be transplanted, and grow on com-
mon or indifferent nutritive material ; they will have no bearing on the
questions concerning the nature and origin of cancerous blood.
At the most, then, we may assume that a transference of cancer by
inoculation is possible. But such an asumption will not materially
diminish the number of cases in which we look in vain for any external
source for the disease, and in which all that we can study are the con-
ditions most favorable for its production within the body. Of these
conditions I have already spoken, in relations to each of the principal
forms of cancer. I need, therefore, do little more than sum up the
general conclusions concerning them.
First, respecting the influence of sexual peculiarities. Women are,
on the whole, more liable to cancer than men are ; but in what propor-
tion they are so cannot be exactly stated : Lebert assigns about 37 per
cent, as the proportion of cancers in males : Dr. Walshc finds it
scarcely more than 26 per cent. This is just one of the points on
which the truth will not be known till statistics are collected by prac-
titioners under whose charge the two sexes, and all the organs of each,
fall in just proportions, and by whom the existence of internal cancers
is as constantly ascertained by autopsy as that of external cancers.
The frequency of cancer of the breast and uterus gives an apparently
large preponderance of cases in women ; but, on the other side, the
cancers of the skin, bones, and digestive organs, greatly predominate
in men. The liability of the breast makes scirrhous cancer by far
most frequent in women : but this in a general estimate, may be nearly
balanced by the preponderance of epithelial, osteoid, and villous can-
cers in men.*
The influence of age may be more definitely stated. Dr. Walshe
has clearly shown that " the mortality from cancer [i, e. the number of
deaths in proportion to the number of persons living] goes on steadily
increasing with each succeeding decade until the eightieth year." His
result is obtained from records of deaths ; but it is almost exactly con-
firmed by the tables I have collected, showing the ages at which the
cancers were first observed by the patients, or ascertained by their
attendants. In 772 cases, including cancers of all kinds, the ages at
which they appeared were as follows :
* The particular influences of sexual difference may be collected from pp. 54*2, 582, 624,
641, 651. On these and all the questions capable of being solved by statistics, the largest
information is collected by Dr. Walshe, and in the tables of Mr. Sibley and Mr. Baker, Mcd.-
Chir. Trans., vols, xlii and xlv.
GENERAL PATHOLOOT OF CANCER.
679
Under
10
years,
. 27
Between 10 and 20
u
. 30
u
20 "
30
u
. 78
u
30 "
40
(I
. 130
u
40 "
50
(i
. 200
u
50 «
60
((
. ir)2
u
60 «
70
u
. 98
u
70 «
80
((
. 57
The proportions between these numbers and the numbers of persons
living at the corresponding ages (calculated in the same manner as in
the previous Lectures, pp. 543-4, 582-3, 625), will show the propor-
tionate frequency of cancer at each period of life, and may be repre-
sented by the following numbers :
Under
10 years
5
Between
10 and 20
u
6-9
4t
20 " 30
ti
21
u
30 " 40
it
48-5
u
40 " 50
(4
. JOO
u
50 " 60
i(
113
l(
60 « 70
i(
. 107
u
70 « 80
U
. 126
Thus, the liability to cancer seems always increasing from childhood
to eighty years of age. A single exception to the rule (between 60 and
70) appears to exist ; but this would very probably not appear in esti-
mates from a larger number of cases. The general fact, and that of
the immense increase of cancer after 40 years of age, are of exceeding
value in proving that it is a disease of degeneracy.
Within this larger rule, others may be collected from the foregoing
Lectures. Of the three chief forms of cancer, the medullary alone ex-
emplifies the rule of frequency constantly increasing from earliest to
latest life ; but the rate of increase is, of course, difierent from that
shown in the general table (p. 582-3). The epithelial cancers exem-
plify the rule after the age of 20 ; before that age they are scarcely found
(p. 625). The scirrhous have their maximum proportionate frequency
between 40 and 50* (p. 543). The melanoid cancers are nearly con-
formed to the rule of the medullary. The osteoid and colloid probably
have rules of frequency peculiar to themselves, and depending upon
local conditions : but we need more cases to calculate them.
The increase in frequency of cancer with increasing years, its great
prevalence after middle age, and the conformity to this rule shown by
medullary cancers which are least of all dependent on locality for
their development, — these facts may prove, as a rule, that cancer is a
disease of general or constitutional degeneracy. But, as in every other
part of the pathology of cancer, so in estimating the influence of age
* It is probably due to this great frequency of scirrhous cancer in the female breast, that
(sB Dr. Walshe found) the increase of mortality from cancer between 40 to 50 is so much
graater in women than in men.
680 INFLUENCE OF CLIMATE.
in its production, we must consider the effect of time in making certain
parts apt to be the seat of cancer. Such an effect is shown in the dif-
ferent liabilities which each organ manifests at different periods of life.
These cannot be exactly stated ; but, beyond doubt, the eye and orbit
are earliest apt to become cancerous ; then the bones, testicles, and the
areolar tissue of the limbs and trunk. These are its chief seats before
30 years of age ; from 30 to 50 it predominates in the penis, uterus,
external sexual organs, and the breasts ; after 50, in the integuments
and digestive organs.* I fear nothing can be said of the real nature
of the changes ensuing in each organ, which thus make it, at different
times of life, jnore or less appropriate for the seat of cancer. In some
parts, as the testicles and limbs, the chief liability seems to coincide
with the first attainment or with the time of failing in the attainment
or maintenance, of full functional power ; in others it falls in with the
beginning of the loss of power, as in the uterus and breast.
Two other conditions seem to have influence in producing or pro-
moting the cancerous constitution : namely, climate, and mental dis-
tress. Dr. Walshe has collected evidence that " the maximum amount
of cancerous disease occurs iti Europe," and that it is very rare among
the patients of the hospitals at Hobart Town and Calcutta, and among
the natives of Egypt, Algiers, Senegal, Arabia, and the tropical parts
of America. We cannot, indeed, be sure that this difference depends
on climate ; it may be due to the national differences in habits of life ;
possibly, as Dr. Walshe suggests (p. 160), the greater prevalence of
cancer may be due to the more wasting influence of the higher state of
civilization. More records are necessary to decide such questions ; and
it may be well if they include accounts of the apparent variations of
cancer among nations whose climate and habits of life are not mate-
rially different. (See pp. 344, 421.)
It is only on a general impression, not by counted facts, that we can
reckon deep mental distress among the conditions favorable to the pro-
duction of cancer. I do not at all suppose that it could of it.self gene-
rate a cancerous condition of the blood ; or that a joyous temper and
prosperity are a safeguard against cancer; but the cases are so fre-
quent in which deep anxiety, deferred hope, and disappointment, are
quickly followed by the growth or increase of cancer, that we can
hardly doubt that mental depression is a weighty addition to the other
influences that favor the development of the cancerous constitution.
Nor is it strange that it should be so ; it is consistent with the many
other facts showing the affinity between cancer and depressed nutrition.
But, after all, when we have assigned to these conditions their full
weight in producing the cancerous constitution or state of the blood,
* More rules of this kind may perhaps be gathered from the statistics of Walshe and Lfr
bert ; but with caution, for want of such records as I have said are necessary to estimate
the liabilities of the sexes.
GENERAL PATHOLOGY OF CANCER. 681
that which may strike us most of all is the comparatively small influ-
ence which any known internal or external conditions possess. We
are, as yet, wholly unaware of any great difference, in the frequency
of cancer, among those of our own nation who are most widely apart
from each other in all the ordinary conditions of life. The Richest and
the poorest alike seem to be subject to it ; so do the worst- and the best-
fed ; those that are living in the best conditions of atmosphere, and
those that are immured in the worst ; those that are cleanly, and those
that are foul ; those of all temperaments, and of all occupations (except
such as have peculiar local influences) ; those that appear healthy and
those that are diseased, except those with some few specific diseases.
We can hardly lay our hand upon any one of the various circumstances
of life, in the various orders of society in this country, to which we can
refer as rendering one more or less liable than another to the acquire-
ment of the cancerous constitution. Dr. Walshe's evidence amply shows
the want of foundation of all the general impressions opposed to this
conclusion.
From this confession of ignorance respecting the production of the
cancerous constitution, or, as I would say, of the cancer-material in
the blood, when it is generated within the body, 1 will proceed to speak
of some of the changes which, being once generated, it may undergo.
In all ordinary events the normal course of cancerous disease is that
of steady progress towards death. The increase is indicated by two
different, but usually commensurate, series of phenomena: those,
namely, of increasing formation of cancer-structures, and of increas-
ing cachexia.
We may commonly observe, that, from the beginning of a cancerous
formation, there is a constant increase in its mass, and in the rate at
which it is added to. Even the cancers that are, in part, ulcerating,
are usually growing, at a greater rate, at the border or surface opposite
to that in which ulceration is destroying them ; or else, while ulcera-
tion is going on in one cancer, there is a greater rate of increase in
others ; or, the number of growing masses is constantly increasing. In
one or more of these methods most cases exemplify the general rule,
that the quantity of cancer which is formed within any given length of
time, regularly increases from the beginning to the end of the case.
In most cases the increasing formation of cancer is accompanied by
manifest indications of increasing cachexia. But it is not always thus ;
in a large number of cases, especially of cancers of external organs,
no cachexia appears till the local disease has made great progress ; and,
on the other hand, we find cases, especially of internal cancers, in
which the cachexia increases without proportionately increasing can-
cerous formations : cases in which we may say that the cancerous con-
dition of the blood manifests itself less plainly in the production of
growths, than in its interference with the ordinary phenomena of life.
Such cases are not unfrequent among those of cancer of the rectum :
44
682 INCREASE OF DIATHESIS.
we see the patient intensely ill, and dying witb cachexia, to which the
extent or rate of growth of the cancerous tumor bears no proportion.
So, sometimes, with cancer of the liver ; the cachexia is quite dispro-
portionate to the amount of cancerous formation, and to the degree in
which it injerferes with the functions of the organ. In these cases, the
cancerous disease exemplifies a frequent event in the history of specific
diseases : namely, that when the morbid material is most intense and
acute in its action, when it most manifestly aficcts the constitution, it
may produce the least indications of local morbid influence.
In both these sets of cases, the increase of cancerous disease, and
its accelerating rate, are illustrated as the rule of its career. The phe-
nomena, in the first set of cases, may be explained by assuming that
the quantity of cancer-material in the blood regularly increases ; those
in the second, that, with its increase, it undergoes some transformation,
rendering it less appropriate for growths, but more injurious to the
other offices of the blood.
(6) The cancerous constitution may apparently cease ; a growth al-
ready formed may maintain itself, subsisting, probably, on the normal
constituents of the blood,* but its progressive increase may be for a
time suspended. I have exemplified this by cases of medullary cancer
(p. 586), of which the general history was, that, after a certain period
of increase, the tumors ceased to enlarge, were for a time stationary
(the general health also remaining the same), and then resumed the
cancerous mode of progress.
{c) The cancerous constitution may be in some measure changed or
modified. It may manifest itself for a time in a certain form of cancer,
and then in some other form. Thus scirrhous cancer may be succeeded,
in secondary growths, by medullary cancer ; osteoid by medullary, and
vice versd ; and, I think, epithelial by medullary. We must, I believe,
in these cases assume a transformation of the specific cancerous mate-
rial in the blood, — a change corresponding with that which may be
more regularly traced in the materials of other specific diseases (e. ^.,
of syphilis) in their successive stages or periods of life (pp. 327, 333).
Lastly, the cancerous diathesis, even after it has been manifested by
growths, may be superseded. Thus, we may express the cessation, or
retrocession, of cancer, when tuberculous disease ensues in its course-
In the last three events the rule of progress in cancer is departed
from. But if we could reckon all the cases in which any of these
events happen, they would make but a few exceptions to the general
rule, that the cancerous constitution regularly increases at an accele-
rating rate, and with little change in its methods of manifesting itself.
* 1 shall revert to this point in the next Lecture. The maintenance, or even theincmse.
of a cancerous growth, does not necessarily imply that a cancerous condition of the blood is
maintained : once formed, a cancer, like any other tumor, may live and grow by its asami'
lutive power over cancerous materials.
GENERAL PATHOLOGY OF CANCER. 683
I pass now to the consideration of the second necessary precedent
of a cancerous growth, namely, the existence of some part fitted to be
its seat — some apt locality. Such fitness may be natural or acquired ;
and in parts in which it is in some measure natural, it may be increased
by accident or disease.
Certain parts of the body are evidently, and independently of ex-
ternal influences, far more liable than others are to become the seats
of cancer. They are, thus, naturally apt localities ; not equally so
throughout life, but usually becoming so at certain periods.
We have no such full and impartial statistical evidence as might
enable us to state clearly the proportions in which the several organs
are primarily or secondarily affected with cancer. There are at pre-
sent, I believe, no large statistics on which we can place reliance for
accurately determining this point ; bills of mortality, founded upon di-
agnoses not confirmed by autopsy, and the records of those whose prac-
tice is chiefly medical or chiefly surgical, supply only unsafe or partial
evidence.
It cannot be doubted that the uterus, stomach, and female breast
hold the first place in aptness for primary cancerous growths ; and the
lymphatics, lungs, and liver, for secondary growths ; and that among
the parts least liable to either affection are the spinal cord, tendons,
tonsils, pharynx, and prostate gland. But beyond these general state-
ments none, I think, can be safely made. Neither does any explana-
tion yet offered of the different liabilities of parts seem well founded.
As Dr. Walshe observes, all that has been said to explain the lia-
bility of the breast and uterus may be equally well said of the ovaries,
which are comparatively rarely cancerous. So, too, what has been
said about the brain and stomach, and testicle, is just as applicable to
the spinal cord, the duodenum, and the epididymis ; yet these parts of
similar systems are, severally, in complete contrast in their aptness to
be the seat of cancer.
It seems impossible, at present, to discover what it is that makes
one part more than another naturally fit to be the seat of cancerous
growth ; or any part more fit at one time of life than at another. We
are, of course, disposed to look for explanation to peculiarities of tissue,
and to their changes with age ; and we can hardly doubt that these
are chiefly influential : and yet, as the medullary cancers of the eye-
ball and orbit show (p.* 577), we must ascribe something to locality as
well as to tissue. The allocation of cancers is certainly not wholly
determined by aptness of structures. An osteoid cancer, for example,
affects at once cancellous and compact osseous tissue, medulla, perios-
teum, and surrounding muscles ; a medullary cancer may occupy, from
the first, many tissues both within and around the eyeball : when a
cancerous breast is cut away, the recurrent growths appear very com-
monly in the scar, ». e. in the same locality, though all the tissues
affected by the primary growth are gone. Very numerous cases such
684 LIABILITY OF CERTAIN PARTS.
as these might be cited ; they cannot, I presume, be explained, but
they suggest the need of considering always that morbid products may
be determined to certain places as well as to certain structuret. As
each natural organ has its appropriate place as well as structure, so,
but with almost infinitely less regularity, morbid growths may have
laws of allocation.
A question of much interest is connected with the liability of other
tumors to become cancerous ; it is of interest not only as a subject of
pathological inquiry, but in relation to an opinion which is often made
a reason for operations : namely, that if a tumor of any kind is left to
its own course, it is not unlikely to become cancerous. I have looked
carefully into this question, and I believe there are no facts sufBcient
to justify the opinion that an innocent tumor is more likely to become
the seat of cancer than many other parts of the body in which it is
growing. The only case supporting such an opinion is that of cystic
disease of the ovary. I think there is no doubt that it is not unfre-
quent for cysts of the ovary to exist, for a time, as an innocent disease,
and then become the seat of cancerous growths. But then, the case
of cystic disease of the ovary is so peculiar in all respects, that we
cannot deduce from it any rule to be applied to instances of other
tumors.
With regard to the supposed transformation of any other tumors into
cancers, the facts are very few.
M. Lebert states that he has twice met with tumors which were at
first of an innocent kind, but afterwards became cancerous ; but he does
not state whether they were in persons who had cancer in some other
part : u e, whether the cancer in the tumor were secondary or primary.
Sir Benjamin Brodie mentions a case in which he removed a tumor,
the general mass of which appeared to be fatty substance, somewhat
more condcDsed than usual, but " here and there was another kind of
morbid growth, apparently belonging to the class of medullary or fun-
goid disease."* A few other cases of the same kind are related; and
some would assume that in all the cases of mixed cartilaginous and can-
cerous tumors (mentioned at p. 450) the cartilaginous growth was being
transformed into, or superseded by, the cancerous one. I see no good
evidence for such an assumption : the contrary might very well be
maintained in argument ; or the two growths might be regarded as
simultaneous in their origin.
It need not be denied that cancerous growths may occur in tumors
that were previously of an innocent kind, but I feel quite sure that
these may be regarded as events of the greatest rarity.
My own experience has (perhaps by chance) been such as would in-
dicate that innocent tumors are less liable to cancer than the structures
they resemble ; for, as I have elsewhere mentioned (p. 491), I have
* Lectures on Pathology and Surgery, p. 282.
EFFECTS OF INJURT AND DISEASE. 685
seen three cases in which cancer affected the natural stracture of the
mammary gland, while, close by, mammary glandular tumors remained
unaffected.
It may be asked, whence is derived the impression that so commonly
exists, that a tumor of an innocent kind is peculiarly apt to become
cancerous ? I believe it has arisen from several different kinds of de-
ceptive cases.
First, there are the cases of what I have referred to as the suspen-
sion, for a time, of cancerous progress ; in these the cancer seems for a
time to be an innocent tumor ; it is judged to be so because it remains
so long quiet ; and when it assumes the ordinary progress of cancer, it
is said to be a tumor once innocent, but now become cancerous. This
might have happened in the first and fourth of the cases mentioned at
p. 586 ; yet, without doubt, in these cases, the tumors that made little
or no progress had all along the cancerous structure.
Another class of deceptive cases have a history of this kind : A tu-
mor is removed which is apparently of an innocent sort ; but, some
time after, a cancer appears at the same part. The explanation of some
of these cases is (as I suggested on p. 491), that a simple tumor has
grown in a person having an hereditary or other constitutional ten-
dency to cancer ; and that, in the removal of this tumor, the surgeon
has unwittingly supplied, by the local injury, what was needed for the
production of a cancerous growth ; he has made some locality apt for
the manifestation of a constitutional disease already existing.
In a third class of cases, we may find in the same person a succes-
sion of tumors, of which the first may have few or no characters of can-
cer, and the last, as if by gradual change, may be evidently cancerous. I
have referred to this in connection with recurrent tumors (p. 510) ; but
the facts have little bearing on the question whether an innocent tumor
can become cancerous ; for here the transition is effected, not in one
tumor, but in a succession of tumors.
By cases such as these, we may, I believe, explain away the grounds
for the assumption that simple or innocent tumors are parts peculiarly
apt to become cancerous. Cancers may grow in such tumors, but the
event is so rare, that it cannot, in any given case, be reasonably anti-
cipated.
It remains to consider how parts may acquire an aptness for cancer-
ous growth in them, or, in most instances, how that aptness which they
naturally possess may be increased ; for it is very observable that the
"exciting causes*' of cancer act with far greatest effect on the parts
which are, without their help, most liable to it.
Three chief conditions may be here enumerated : namely, the results
of certain diseases in intra-uterine life, indicated by congenital defect ;
the results of certain diseases after birth ; the consequences of injury.
The aptness for cancer due to congenital defect is exemplified in the
peculiar liability of moles or pigmentary nsevi to become the primary
686 GENERAL PATHOLOGT OF CANCER.
seats of melanosis. I have already enlarged on this (p. 643), and have
suggested that these defects, which we can easily see, may be only ex-
amples of a larger group which, though invisible, are not less efficient
in rendering certain parts peculiarly liable to cancer.
The aptness due to diseases after birth may be illustrated by the
liability of the incrustcd warts and scars, and other morbidly changed
parts, to become the primary scats of epithelial cancers. For other
than epithelial cancers the effect of disease in disposing parts to cancer
is slight. We find no remarkable liability in parts that have been
changed by inflammation, whether of common or specific kind. Few
theories, I think, have been less founded than those which have re-
garded scirrhous or medullary cancer as, in any sense, the result or
sequence of inflammation. Farts that have been the seats of inflamma-
tion may become the seats of cancer ; but I doubt w^hether the propor-
tion in which they do so be much greater than that in which they
become cancerous when apparently healthy.
The influence of injuries is more evident. About a fifth of those who
have cancer ascribe it to injury; and although, doubtless, some of these
are wrong in their belief, yet, among the rest, there are some in whom
the consequence of injury is too evident to admit of doubt. But here
a distinction must be made as to the manner in which injury promotes
the production of cancers.
In certain cases the cancerous growth appears immediately after the
common effects of the injury. A person receives (suppose) a blow, and
when its direct effects are passing away, a cancer appears in the in-
jured part. I have cited cases of this kind in the history of medullary
cancers (p. 584) ; among which, indeed, the event seems more frequent
than among those of other forms.
In other and more usual cases, a much longer interval passes between
the injury and the appearance of the cancer. The injured part seems
to recover without change of structure. In most cases, indeed, such as
those of ordinary blows on the breast, the direct effects of the injury
are not such as we might expect to be followed by structural change,
yet doubtless, the part remains different from what it was.
In a third class of cases, which are most frequently exemplified in
the epithelial cancers, the injuries appear to be ineffective unless they
are repeated time after time, so as to produce, we may suppose, a real
change of structure in the part that at length becomes the seat of
cancer (p. 627).
It is important to remember these different relations between in-
juries and the growth of cancers, not only for pathology's sake, but for
practice.
It is often stated, as a rule, that those cancers are least likely to
return (it should be said, to return quickly), after removal, which have
followed the seat of injury, or some previous disease in the part. Now.
this is only partially true ; it is probably often true of the epithelial
QUESTION OF CANCEROUS TRANSFORMATION. 687
cancers that have grown in the seats of repeated injury, of frequent
ulceration, and the like ; but I know no facts relating to scirrhous and
medullary cancers that will support it ; and I believe that the cases in
which cancers follow quickly after accidental injury are just those in
which a speedy return may be anticipated after operations. The growth
of a cancer im^iediately after an injury implies the existence of an in-
tense cancerous diathesis, which no removal of the cancer is likely to
affect ; but when a part has been repeatedly injured, and only at length
becomes the seat of cancer, it implies such a low degree or state of
cancerous diathesis, as we may expect to remain long ^Matent*' if the
fllowly-prepared locality, with all that has grown in it, be cleanly re-
moved. Of the intermediate cases, in which some clear time intervenes
between the injury and the growth of the cancer, we must hold, I think,
that the abiding effects of the injury keep the part in a state peculiarly
apt for the growth, till the constitutional condition is established. This
being complete, the removal of the growth cannot change it ; and the
injury done by the operation would be enough to prepare a place, if
none else were appropriate, for a recurrent cancer.
LECTURE XXXV.
GENERAL PATHOLOGY OF CANCER.
PART n.
STKUCTURB iND LIFE OF CnNCEROUS GROWTHS.
I BNDBAVORED to illustrate, in the last Lecture, those two conditions
which, judging from the general history of cancers, and the analogy of
other specific diseases, we must assume as necessary precedents of a
cancerous growth : namely, the cancerous diathesis, constitution, or
morbid condition of the blood, and the condition of some part appro-
priate for the growth. Now, according to the same analogy, the as-
sumed cancer-material in the blood, if it cannot be removed by any
natural excretory organ, will determine the formation of some abnor-
mal organism in which itself may be incorporated ; and this organism
will have a specific structure and mode of life significant of its origin.
It is of these — the general structure, composition, and life of cancerous
growths — that I shall now speak.
It may be generally held that the characteristic structures of a can-
cer are altogether of new formation. But questions are often raised
wliflticr natural strnotures may not he tr&nafg
or, whether cancerous muterials may not ht
the blood into the natural textures ; or, whether natnfHl Btntcturei tu
aesumo cancerous properties, I believe such qucHtioitfl tony b* tbtt
answered :
(1) It is not probable that any structure, once r»tnpl«tely fanaii,
can he transformed into any other. Structures mar ohuiie by Re-
generation ; hut in this their changes are as liuiUil and a«miniial«ii
development. Th« instances in which natural or oth«r stntrlwoM
supposed tu become canccrouM arc, chiefly, Ihosu in whiufa Ofrw-foml
can cer-Htr not uvea are inserted or infiltrated amcmg, or, swaMdnt^
within, those of the afTcoted part. Uf such ca»e« wc way sty UmI (ht
pari becomes the seat of cancer ; not that it becomea anceroni.
(2) It is posi^ible that, in the mutation of struotnrca eCiMtadmlkl
nutrition of certain parts, the elemental structures soceeauTelj teta^
may gradually amumo the uppearanco and proporticf of tlMMoTci^
oer. It has often been observed, in cases of cancer of the liver, (IM
every grtulation of structure apptiirs, from the natural to ihc ctaM^
ous; and that, among the microscopic structures, arc many ofwlikbit
U hanl to say wliclhcr they be hepatic onUn or cancer-w]la. Itmif
be that thin only exi>mpli&cs the tendency of canccr-stnctnnM to M
conformed, in some measure, to those of the adjacent itaiun) pam;
but it may also be, that both thu fact and Ihw woll-known Unitatj
ftre evidences that cancerous properties may be gradually imparleil ta
the elementary structures in a part, ho that m they arc t>uccc«M>rlT
formed they may gradually assume more of the characters of cancer.
In other words, as in inflammations we observe the wider deviatiou
from the normal methods of nutrition or secretion, the larger the pro-
portions are in which the inflammatory exudation is mingled with t)»
normal products of the part (p. 241) ; so, it may be, increasiDg qauB-
ties of cancerous material, added to the natural elementa of the tex-
ture, may he represented by successive gradations of stmetare. 1
cannot doubt, therefore, that transformation into cancer is, in this sesM,
possible.
(3) It is possible that undeveloped cancer-material may be sepantd
from the blood, with the materials of natural excretory organs, and wmj
be for a time incorporated with the transient structures of sucfa orgnt.
We may assume this from the analogy of the cases in which we bdien
that other specific morbid materials are thus eliminated from the bloa^
as well as of the cases in which certain materials, which shoaM be Mp*-
rated from the blood by appropriate organs, are, when the office ot thoM
organs is hindered, vicariously eliminated by others. In both thcM
cases we believe that alien materials are, for a time, incorporated in tkt
structures of the eliminating glands, and then discharged ; and it ii. ii
like munuer, possible that cancer-materials, though their onUnary (••
QUESTION OP CANCEROUS TRANSFORMATION.
689
dency is to determine the formation of peculiar structures for their in-
corporation, may be incorporated in those of natural glands.'*'
* From Dumerous observations made during the last few years, it would appear that the
characteristic cancer-cells and nuclei may, like the corpuscles of pus, take their rise from the
pre-existing cells and nuclei of the texture or organ in which the new growth originates.
This mode of origin of the structural elements of cancer was first pointed out by Virchow,
and he has more particularly directed attention to the changes which take place in the con-
nective tissue during the development and growth of cancer in it. This process he has
illustrated and described in carcinoma of the breast, in Lecture XIX of his Cellular Patbo-
logie. From these observations, it would appear that the formation of well-defined cancer-
structures is preceded by definite changes in the corpuscles of the connective tissue of the
part. Their nuclei divide and increase in number ; the corpuscles themselves swell out so
as to be accommodated to the increased endogenous development of the nuclei : the cor-
puscles may tlien divide, and this division may take place in such a way as to form rows
of small young ceils in the spots where normally only one corpuscle existed. By the per-
sistence of this process, groups of new cells are produced, which gradually assume the ap-
pearance of cancer-cells. These are contained in loculi or spaces, the boundaries of which
are formed by the fibrous element of the connective tissue. Changes of a closely corres-
ponding nature in a case of carcinoma ventriculi have been figured and described by Fors-
ter in his Atlas (Taf. xxvii, Fig. 2).
It is not, however, in the connective tissue only that the development of the cancer-cells
from the normal teztural elements has been traced. In the muscular fibre also, distinct and
satisfactory evidence has been obtained. C. O. Weber (Virchow's Archiv, xv, pi. xi) has
furnished excellent illustrations of it in cases nf scirrhous and epithelial cancer of the tongue
and lips, and Dr. Neumann (Ibid., xx, p. 15'2) has demonstrated the same in the pectoralis
major, in a case of hard cancer of the breast.
The editor has also had excelientopportunitiesof following out the process irfthe muscles
of a man, the whole of whose scapula, with its proper muscles, Mr. Syme excised for a large
soft cancerous tumor, involving the glenoid
fossa and neck of the bone, and the muscles Fig. 115.
connected with its dorsal and ventral aspects.
In many of the muscular fibres the well-
known changes of structure produced by
fatty degeneration were seen ; but in others,
especially after the addition of acetic acid,
changes of another character could be dis-
tinctly traced. In some of these commencing
division of the nuclei was observed ; in others
this division had gone on to a much greater
extent, so that where but a single nucleus
had originally existed, now numbers might
be seen. And these were arranged either in
long rows, some of which were situated close
to the edge of the fibre, others more in its
substance, or else were clustered together in irregular groups (o, Fig. 115). In many spe-
cimens both the linear and clustered arrangements could bo seen in the same fibre, and
when these were largely developed, all trace of the transverse striie had disappeared, and
the fibre was completely filled with young brood (6). A still further stage, evidently indi-
cating disintegration of the fibre, was also noticed in many of these. Their regular outlines
no longer existed, and instead, they possessed a jagged appearance as if breaking up, and
adding their quota of contained structures to the collections of nuclei and small rounded cells
met with in large quantities in those localities iu which these disintegrating fibres were seen.
These processes were followed out in the muscles surrounding, and in contact with, the ex-
terior of the cancerous tumor. Now, by the extension of these destructive changes, more
and more of the muscular substance had necessarily become involved ; the increase in size
of the tumor and the enlargement of its boundaries, being evidently primarily due to the
a/
690 GENERAL PATHOLOGY OF CANCBB.
So far, then, as the gradual change accomplished in a saccession of
structures, or the introduction of cancer-materials into the elemental
structures of excretory organs, can be called a transformation, the term
is not chargeable with the absurdity which some impute to it. And the
belief of the possible transference of cancer-material into some gland-
structure is worth holding, for it encourages one of the few hopes of
curing cancer that at present seem reasonable, — the hope, namely, that
means may be found by which the morbid substance, transformed or
combined, may be constantly eliminated from the blood through the
transient structures of some gland.
But these things are only possible : the unhappy rule is, that the
natural consequence of the cancerous condition of the blood is, sooner
or later, the formation of a cancer with specific structures and mode of
life. Concerning these, it may suffice if I collect and comment upon
the principal facts detailed in the foregoing Lectures.
In general construction, cancers may be either infiltrations or sepa-
rate masses: i. e., their elementary structures may be either com-
mingled, and form one mass, with those of a certain portion of a natural
part, or they may be collected unmixed in a mass around which the
natural tissues are extended. In any case, the mass they form is a
growing part ; and herein is the ground for classing them with tumors,
and for separating them from those results of disease, such as inflam-
matory products and tubercle, which may be increased, but probably
not by their own power of growth. (See p. 338, &c.)
In both their likeness and their unlikeness to other tumors, cancers
exemplify what is common among specific diseases, namely, that they
take certain general characters of common diseases, and, as it were,
stamp them with some specific mark. Syphilitic eruptions are known
by some specific character, added to those which arc common to other
eruptions of the same group : each specific form of ulcer has its own,
together with common, characters ; so, cancers have many characters
in common with other tumors, but specific cancers are superadded. (See
p. 323.)
When, as in infiltrations, the cancer-structures are mingled with those
of a natural part, the most frequent event is, that the growth of the
cancer preponderates, and at length excludes that of the natural struc-
>
multiplicatiuri of the nuclei, which, through resulting disintegration of the fibres, were con-
tinually being added to the circumference of the cancerous tumor, and there assumetl the
appearance and characters of true cancerous elements.
Thus, within the muscular fibre itself, and from its pre-existing nuclear elements, the
descent of the proper cancer-cells and nuclei could be distinctly traced ; and this too in a
texture which, from the very nature of its structure, precludes all possibility of an exiula-
tion or blastema being poured out into it. (A description by Mr. Syme of this case of ex-
cision of the scapula may be found in the April number of the Edinburgh Med. Jal. fl»r
1863, p. <jr)l J and at p. 873 of the same number, the editor has entered more at length into
the discussion of the question of the mode of origin, not only of the corpuscles of cancer, btil
of those of tubercle and pus.)
GENERAL CONSTRUCTION OF CANCER. 691
tares; so that, finally, the latter disappear, and a substitution (to use
M. Lebert's term) of cancer in the place of the natural tissues, is
effected. But the reverse of this sometimes happens ; instead of atro-
phy, hypertrophy ensues in the natural structures of the affected part ;
and within the same area both normal and abnormal structures grow
excessively. Thus it is with the growths of bone that form skeletons of
the medullary cancers, and with those of connective tissue that extend
into the exuberant epithelial cancers.
The developed cancer-structures, if we except the few cases in which
they are fibrous or osseous (pp. 540, 649), may be generally described
as formed of nucleated cells, or of such corpuscles as are rudimental
of, or degenerate from, the nucleated cell. Herein, and in the fact
that the corpuscles are neither imbedded in formed intercellular sub-
stance, nor orderly arranged, lies one of the characters by which cancers
are distinguished from other tumors, and from all natural parts. Their
chief heterology, in respect of construction, is in this disorderly crowd-
ing of their elements ; and I believe it is constant, unless when they
imitate the plan of some adjacent natural gland-structure (pp. 569, 578).
We observe, in the large majority of cancers, two primary or founda-
tion-forms of cells, of which the respective types may be found in
gland-cells, and in epithelial or epidermal cells. Of the former, we
have examples in the ordinary cells of scirrhous and medullary cancers
(pp. 626, 570); of the latter, in the ordinary epithelial cancer-cells
(p. 610) ; and it is, perhaps, very significant of the meaning of cancer,
that the forms which its structures are most prone to assume are after
the pattern of those belonging to the natural structures whose oflSce is
to separate whatever is refuse or abnormal from the blood.
I say, the cancer-cells are formed on the types of excretory gland-
cells and epidermal cells ; yet without deviating from the general type,
they have special characters by which it is seldom diflScult to distin-
guish them. The question is often asked, What are the characters of
the true cancer-cell ? or. Has the microscope discovered any structure
which is decisive of cancer, wherever it is found ? The answers may
be, — (1.) Where cells, such as are described at pp. 526 and 610 are
found alone, or chiefly, composing a tumor, we may be certain that the
tumor is a cancer : we may, therefore, regard these as especially can-
cer-cells. (2.) When a tumor is composed, chiefly, or alone, of cor-
puscles, such as the nuclei described at p. 509, or any others which we
can trace as rudiments or degenerations of the cancer-cells, the diag-
nosis of cancer is not less certain : structures such as these are found
composing none but cancerous tumors. . But if the question be changed
to, — Are there any cancers which are not formed of structures such as
these ? — the answer must be affirmative : for there are rare tumors
which present the whole clinical history of cancers, and which should
therefore be called by the same name, though they have not these pecu-
liar cancer-structures, or have them in very subordinate quantity. I
692 GENERAL PATHOLOGY OF CANCER.
do not refer here to cancers of which all the structures are imperfect,
or degenerate, or diseased ; but to such as the fibrous cancers (p. 540),
the osteoid (p. 646), and certain varieties of the medullary (pp. 570 to
572).* These all deviate from the assumed specific cancer-structures;
and two of these, the fibrous and osteoid, approximate to the characters
of natural tissues.
Together with the disorderly construction, and the peculiar cell-fornis,
we may often observe, as characteristics of cancers, the multiformity of
the structures composing their mass. It is not equalled, I think, bj
any tumors, unless they be the cartilaginous or the mixed glandular
and cartilaginous (pp. 437, 454). The variety of forms appears due, in
part, to the mingling of the perfect structures with such as are in va-
rious stages of development and degeneration ; and, in part, to what
seems like a disorderly overgrowth and endogenous increase in cells and
their contents. All these forms have been already described; but they
may be thus enumerated and arranged : (1.) The chief of those to be
referred to incomplete development are the free nuclei, and abundant
undeveloped liquid or cancer-juice (pp. 527, 568, 610). (2.) The chief
forms due to the degeneration are the transitions from cancer-cells or
nuclei to granule masses (pp. 528, 610) ; the withering corpuscles with
fatty degeneration found in the material like tubercle in cancers (527,
e. s.) ; the calcareous deposits (p. 589) ; the abundant granular matter;
and the occasionally mingling melanoid cells (p. 640). (3.) Overgrown
or abnormally developed corpuscles are seen in the various extensions
of cell-walls into angles and processes (pp. 526, 571, 611) ; and in the
enlargement of free nuclei and their assumption of the characters of
nucleated colls (pp. 527, 569, 611). (4.) The endogenous increase in
cells is exemplified in all that is described of the brood-cells and lami-
nated corpuscles of the epithelial and colloid cancers (pp. 613, 661).
It would be too tedious even to enumerate more forms than these of
the component cancer-structures, and I need not again describe them.
It is not their multiformity, so much as the existence of many of them
in a single mass, that is generally characteristic of cancer.
Various as are these corpuscles of cancers, it is yet to be observed
that there is none so entirely diiferent from those of normal structures,
that we cannot point out among them its type or parallel. No obser-
vation since Mlillcr's time has invalidated his demonstration of this
principle. The experienced microscopist will, indeed, very rarely fail
in the diagnosis of a cancer by its minute structures ; but he only dis-
criminates them as specific modifications of the nucleus, nucleated cell,
* So!iie pathologists would exclude from the name of cancer all these tumors, and all
which are not composed of the "specific'' cancer-structures; but I feel sure that we shall
do ripht if (when a choice must be made) we choose modes of life, rather than sinictures,
for iletermining the afliniiies of morbid j)ro(lucts, and for arranging them imder generic
names. As of all tumors, so, especially of cancers, the true nature is to be apprehended
only by studying them as living things. (Compare pp. 339, 509, 665.)
CANCBR-STRUCTURES, CANCER-CELLS, ETC. 693
endogenous cells, and other forms, of which the types are in natural
parts ; he finds among them no new type-forms.*
In like manner, the elemental cancer-structures show no method of
growth or development which is without parallel in natural structures ;
they are formed and increased according to the same general laws as
are observed in the normal rudimental structures ; their peculiarities,
in this regard, are chiefly in the seeming disorder that often prevails
among them, — in the absence of an apparent singleness of design.
The abundance of cell-structures in cancers has suggested that they
are lowly organized, and many consequences have been hence deduced.
The terms "high" and "low," in relation to structures, are derived
from very arbitrary estimates, and are too fallacious for any important
deduction in pathology ; still, it may be observed, that among morbid
products, cancers should stand high rather than low ; for their ele-
mental forms are on a level with those of natural excretory organs, and
more developed than any but the best inflammatory lymph. If there
were any correspondence, such as has been assumed, between lowness
of organization and malignancy, the ordinary croupous or corpuscular
lymph should be a much worse material than cancer ; but malignant
properties, like malignant spirits, are not confined to the vilest forms.
The proper structures of cancers are supported and held together by
fibrous, membranous, or other connective tissue, forming their "stroma."
This stroma, as I have elsewhere described, is formed, in the case of
cancerous infiltrations, by the natural fibrous or other tissues of the in-
filtrated part, which, in difierent cases, arc either gradually reduced in
quantity or increased. In these cases the stroma is no proper cancer-
structure, and varies with the nature of the afl'ected part (pp. 531, 566,
604). But in distinct, isolable, cancerous tumors, a stroma is formed
appropriate to the cancer, and, in many cases, with a definite mode of
growth, — the dendritic mode (pp. 575, 655). Generally, however, it is
only in its plan or construction that the stroma is peculiar ; its tissues
are simply membranous, or nucleated, or filamentous, or it may be os-
seous: they are not cancerous.f We see, therefore, in cancers thus
formed, as well as in the cancerous infiltrations with overgrowth of the
* This is now sufficiently evident for all the simple cells and nuclei of cancer; and the
more complex endogenous cells and developing nuclei iind tlieir parallels especially in car-
tilage, the preparatory structure of medulla, and the thyroid and similar glands. (See,
especially, Rokitansky •* Die Kropf," and " Ueber die Cysie ;' and Virchow, in his Archiv,
B.iii.)
"f Exceptions to this statement must be made for certain fibrous and oi-iteoid cancers, in
which the fibrous and osseous tissue, if regarded as a stroma for the mingled cancer-cells,
must be admitted as a proper cancer-structure; and for some cases of medullary cancer, in
which a kind of stroma is described as formed of series of elongated cancer-cells.
It must be observed, also, that the line between infiltrations and isolable tumors is here,
M elsewhere, somewhat artificially drawn. It is not to be denied that the latter may in-
▼oItc small portions of natural tissues, which may remain intersecting or partitioning their
masses, and supplying a framework upon which their peculiar stroma may be constructed.
694 GENERAL PATHOLOOT OF CANCER.
natural structures, the coincident growth of morbid and of normal tis-
sues within the same area, and out of the same mixed materials.
With the stroma of cancers are their bloodvessels, among which wc
must again distinguish, as in the preceding paragraph, that some are '
the vessels of the affected part now involved in the cancerous infiltrn-
tion, others are new-formed. Concerning the changes which the first-
named may undergo in the growth of the cancer, we have, I believe, at
present, no knowledge. They are not, as in tuberculous infiltrations,
gradually destroyed or removed ; rather they seem to be increased ; so
that an injected scirrhous cancer of the breast (for example) often ap-
pears more vascular than the adjacent substance of the mammary gland,
though, in the first instance, it had only the bloodvessels of the part of
the gland which it occupies. No direct observations, however, have
shown the method of this increase.
The new-formed bloodvessels of the isolable cancers and the cancer-
ous outgrowths extend from those of the adjacent parts. It is by some
thought that they are formed as an isolated system of tubes in the can-
cer: I know no satisfactory evidence of this ; and the associated theory
of blood being formed in the substance of a cancer, and out of cancer-
materials, seems to me wholly untenable. The method in which the
new vessels extend into cancers has not yet been traced, but is proba-
bly not dijfferent from that observed in other new-formations (pp. 159,
255). Neither has anything specific in their structure or method of
arrangement been yet observed. The descriptions already given of
them (pp. 565 and 656) will show that the bloodvessels of cancers do
not diifer from those of other abnormal growths, except in that gene-
rally, their calibre is more than proportionate to the thickness or com-
plexity of structure of their walls. Hence the term " colossal capilla-
ries;'* and hence, when the bloodvessels are abundant, the likeness to
the simple vascular erectile tumors : but in neither of these respects are
the vessels of cancer without parallel in those of natural parts ; those
of the placenta and of the cavernous erectile tissue might be their types.
Such are the component structures of cancers. We might hope that
chemistry, carrying its analysis far beyond the reach of sight, would
find in them something as different from natural compositions, as their
mode of life is from that of any natural member of the body. But it
has failed to do this ; and the numerous analyses made since those of
Miiller have not materially added to his results.* In a general com-
parison, the cancers are distinguished by the predominancp or exclu-
sive existence of albuminous compounds, while in the non-canceroos
tumors gelatinous compounds (or in the adipose tumors, the fatty) are
the chief constituents. But there are large exceptions on both sides.
The fibrous and osteoid cancers yield abundant gelatine ; the albumi-
* The best of these analyses may be found in Lebert's Traill Pratique, p. 44. e. s.
LIFE OP CANCERS: GROWTH. 695
nous sarcomata of Mailer (including, probably, many of the least de-
veloped proliferous cystic tumors and the recurring fibroid tumors) are
as albuminous as the typical cancers. It is probable, moreover, that
the broad general difference between albuminous and gelatinous growths
is not directly related to their respective properties, as malignant and
innocent, but to their retaining or passing beyond the cell-form.
The want of a mere definite result from chemical analysis is not to
be ascribed to the absence of difference between cancerous and normal
materials, — we may be nearly sure that they are chemically essentially
distinct, — but, rather, to the fact, that an exact analysis of cancer-struc-
tures is nearly impossible. That which would be given to a chemist
for examination is not a pure cancer-material, but a mixture of it with
the materials of blood, bloodvessels, connective tissue, and, in many
cases, of the natural or degenerate structures of the part in which the
cancer has been growing. Add to this, that, in every sample, the can-
cer-structures themselves are, probably, in all stages of development
and degeneration, and the search for the essential chemical properties
of cancer will surely seem as difficult as it would be to find those of
muscle, or of bone, in the analysis of the whole of a foetal, or of a
paralytic limb.'*'
In studying the life of a cancerous growth, we have always to con-
sider it as adding to the conditions of disease which already existed,
and which usually still continue ; it is a new factor in an already com-
plex morbid process. The formation of cancerous material in the blood
does not cease because some is incorporated in a growth ; the transfor-
mations of parts, making them apt for the allocation of cancer, do not
cease because one part is occupied. In all the history of cancers,
therefore, we have to study the continuation of those processes which I
have described in the last Lecture, as preceding the growth of the can-
cer, and which now (with rare exceptions) are concurrent with it, and
increase with it.
Before the formation of a cancerous growth, we trace two distinct,
though usually concurrent, processes ; namely, that which leads to the
cancerous condition of the blood, and that which makes certain parts
fit to be seats of cancerous growths. When once a growth is formed,
it introduces a third element of disease, without necessarily removing
or diminishing either of those that preceded it. As a living part, the
cancer, like any other tumor, has the power of self-maintenance and of
growth, which power, though favored by the continued or increasing
cancerous condition of the blood, is, probably, not dependent thereon.
Also, in the results of its nutrition, the cancer reacts upon the blood,
and through it influences the whole economy ; and these influences are
* The case of the colloid material may seem not open to this objection ; but the colloid is,
probably, not a true cancer-substance, but the product of disease in cancer.
696 GENERAL PATHOLOGY OP CANCER.
addod to the cancerous diathesis or cachexia which is usually, at the
same time and of itself, increasing.
The manifestations of life in a cancer may be divided (but it is too
artificial a division to be followed far) into those which are progressive
and those which are retrogressive. The latter are traced in the various
degenerations and diseases of its structures ; the former in its gro?rtli,
extension, and multiplication.
The chief characteristics of the growth of cancers are seen, in those
that are infiltrated, in their invasion of all tissues, as if indifferently.
Thus the scirrhous cancer of the breast, though limited for a time to
the mammary gland, at length extends beyond it, and gradually occu-
pies every surrounding part alike : thus the epithelial cancer extends
from the integument of the lip to its muscles, glands, and all deeper
tissues, and thence to the gum and jaw ; and thus the medullary cancer
grows into and through the walls of bloodvessels and other canals, and
extends, among their contents, along their cavities. Such reckless
growth (if it may be so called) is scarcely known except in cancers.
They supply, also, the instances of most rapid increase ; but although
they do this frequently enough to make rapid growth one of the diag-
nostic signs of cancers, yet the cases are far from rare in which the
growth is very slow. Few diseases are more variable than cancers are
in this respect. (Compare pp. 631, 585, 631.)
It has been assumed that the appearances of endogenous increase in
certain cancer-cells are indicative of a peculiar inherent capacity of
growth. But this is far from certain, and is made improbable by the
fact that the endogenous productions are most abundant in epithelial
cancers, whose average rate of increase is least ; and that those medul-
lary cancers which have only free nuclei, or imperfect nucleated cells,
are among those of most rapid growth. The rule is more nearly true,
which these instances exemplify, that the rapidity of growth among
cancers is inversely proportionate to the development of their elemental
textures. But this finds exceptions in the very quickly increasing and
multiplying fibrous and osteoid cancers.
Two things administer to the growth of a cancer ; namely, (1) the
continued formation of the specific material in the blood ; and (2) the
inherent power in the cancer, as a living part, to assimilate to itself the
common or indifferent materials of the blood. The first of these main-
tains and augments, as it originated, the growth ; the second effects an
independent increase, like that of a non-cancerous tumor.
In ordinary cases, both these conditions are engaged in the growth
of cancer ; but, if the first fail, the second may suffice. The cancerous
diathesis may cease, or be exhausted for a time, or sometimes even per-
manently ; cancer material, we may suppose, is no longer formed in the
blood ; yet the cancer may subsist and increase by its own power. It
does so like any other tumor ; especially like those which I mentioned
EXTENSION IN LYMPHATICS. 697
(p. 348) as beginning during or after some general disease, but continu-
ing to grow when that disease had ceased.
Now, in this state, the cancer is essentially a local disease, living upon
the materials of blood restored to health, though capable, probably, of
infecting that blood, and inducing secondary phenomena of extension
and multiplication. It illustrates, in this state, a principle which we
are too apt to forget : namely, that diseases of constitutional origin
may become wholly local. The origin of local diseases in constitutional
conditions has been well studied, and the necessity of constitutional
treatment, in chronic as well as in acute diseases, has been rightly re-
ferred to the local ajBfections being maintained by the continued morbid
condition of the blood ; but it has been less considered that, after the
constitutional disease has ceased, the local one may, of itself, continue,
and need local treatment. Such cases are very frequent. One often
sees syphilitic ulcers, which, doubtless, had a constitutional origin, and
were maintained by specific material in the blood, and would have
needed specific treatment of the blood for their cure ; but now, while
retaining their specific forms, they are curable by local treatment alone.
Just so it may be, though very rarely, with cancers. While the cancer-
OQS diathesis is suspended, they may subsist by their own powers of
assimilation; and I believe the few credible cases of recovery after
operation are to be referred to the chances which have led to the
occasional removal of such as were thus localized.
The extension of cancer (so far as it may be distinguished from their
growth) is that which takes place through lymphatic vessels to their
glands. The number of cases in which lymphatics, filled with cancer,
have been traced from the primary growth to the nearest glands, is
sufficient to make it probable that the disease often thus extends con-
tinuously from the one to the other ; and that it is thus, as Mr. Simon
expresses it, transferred by " continuity of blastema.** But, even when
such tracts of cancer cannot be traced from the primary disease to that
in the lymphatic glands, I think Mr. Simon's suggestion is very proba-
bly true, — that the disease is one of the lymph, not of the parenchyma
or vessels of the glands. We do not, indeed, yet know exactly the de-
rivation of the lymph, nor what is its relation to the materials of the
part from which it comes ; but what we do know of it is consistent with
the belief, that lymph, from the seat of specific disease, is likely to con-
tain such of the materials of the disease as may either be carried to
the blood, or may be organized in the lymph after the same plan as in
their primary seat.
The characters of the secondary cancers thus formed in lymphatic
glands, are already described (pp. 533, 580, 616, &c.); and these gene-
ral principles may be gathered concerning them.
(1.) The disease in the lymphatic glands usually repeats exactly that
in the primary seat ; the apparent difierences between them depend
45
698 GENERAL PATHOLOGY OF CANCER.
only on the structures among which the cancerous elements are placed.
But this rule is not without exceptions (p. 534, &c., as cited above).
(2.) The cancer in the glands seldom appears before that in the pri-
mary seat has made considerable progress. At a general rough esti-
mate, it appears about midway in the course of the disease towards
death. The delay is, perhaps, not to be explained, seeing that lymph
is carried from the primary disease as well in its earlier as in its later
stages.
(3.) While the disease in the glands makes progress, the primary dis-
ease usually keeps the lead which its earlier origin gives it. Occasion-
ally, however, that in the glands so far surpasses it that we are in dan-
ger of overlooking the primary disease (p. 534, &c.). I do not know how
the fact can be explained ; but it has its parallel in the occurrence of
primary cancer in the glands that are usually secondarily diseased, and
in the recurrence of cancers after operations in the glands, rather than
in or near its primary seat.
(4.) The lymphatic glands usually become cancerous in direct succes-
sion from the primary disease to the thoracic duct. The extension is,
generally, made slowly ; in scirrhous and epithelial cancers, the disease
often remains long limited to the glands nearest to its primary seat ; in
nearly all cases, also, it is prone to increase in these proximate glands
much more than in those more distant. Rarely, the secondary cancer
appears in distant rather than in proximate glands ; but in these cases,
it illustrates the multiplication, not the extension, of disease.
The multiplication or discontinuous increase of cancers may take
place in the following ways :
(1) The cancer-growth may multiply itself, from its primary seat, to
a part not directly continuous, but in contact, therewith. Thus Dr.
Hodgkin and Dr. Budd relate cases of cancer in abdominal and pelvic
viscera, with corresponding formations on the portion of parietal peri-
toneum or other parts in contact with them ; and thus there may be
correspondence and contact of cancers on the two layers of pleura, or
on the glans and prepuce.
(2) The multiplication may take place on a surface not in contact,
but continuous, with the primary seat ; as in cases by Mr. Simon (1. c),
in which cancerous growths were found scattered along the tract of mu-
cous membrane leading from primary cancers in the kidney and lung.
In both these cases, the multiplication of the cancers seems to be the
result of simple transference of the materials from the primary to the
secondary seat of growth : it is eifected by a kind of inoculation. The
materials of a cancer pass from its mass, and develop themselves, and
grow, where they rest.
(3) Cancers are multiplied in parts neither directly continuous, nor
in contact, with the primary seat. In some instances the parts are near,
in others remote from, the primary disease.
When cancers are thus multiplied near their primary seat by " irra-
MULTIPLICATION OP CANCBRS. 699
diation/' we find them, as it were, springing up in an area which gradu-
ally widens, and of which the primary cancer is the centre. Thus it
is with the tubercles in the skin and muscles near a scirrhous breast
(p. 535); and with the secondary medullary, osteoid, and melanoid
growths scattered around the main disease, but separated from it by
intervals of healthy tissue (pp. 644, 651).
I do not know that we can explain this mode of increase of cancers
otherwise than by reference to the seeming tendency of specific diseases
to be allocated, not only in certain tissues or organs, but in certain
places or regions (p. 577). Certainly, peculiarities of tissue have little
to do with this grouping of the cancers around the primary formation ;
for they may be found, promiscuously, in all the surrounding tissues
within a certain area. Neither does the course of lymphatic or other
vessels seem to determine their places.
In the increase of cancers by multiplications distant from the pri-
mary growth, there is scarcely an organ that may not be afllected. We
see this most easily in the cases of melanoid cancers ; yet their multi-
plicity is, probably, not greater than that of other medullary cancers
(see p. 439). The cancers that thus least frequently multiply are the
epithelial and colloid, and those, of whatever kind, in the rectum, uri-
nary organs, uterus, and brain. The organs in which the secondary can-
cers formed by multiplication are most frequently found are the liver and
lungs. After these organs, the most frequent seats of such secondary
cancers are, I believe, the pleura, bones, lymphatic glands, and subcu-
taneous tissue ; after these, no rule or proportion can be stated, except
that many of the organs in which primary cancers are most frequent
are very rarely the seat of secondary cancer ; e. g.^ the breast, uterus,
testicle, and stomach.'*'
At present, probably, none but a very general explanation of this
multiplication of cancers can be given : we can scarcely venture to guess
what determines the above-mentioned peculiarities. The general ex-
planation may refer the multiplication to two sources, which are in-
dependent, though concurrent and mutually influential; namely, the
increasing cancerous diathesis or morbid condition of the blood, and
the conveyance and transplantation of cancerous matter by the circu-
lating blood.
The constant increase of the morbid condition of the blood was
shown, in the last Lecture, to be a general fact in the history of can-
cers. And, though it may sometimes be represented only by the accele-
rating growth of the primary tumor, yet we might well expect that it
would often produce a numerical increase of cancers. The common
indication of the most intensely constitutional cancerous disease is the
simultaneous or rapid formation of numerous prfmary growths in differ-
ent parts. This is sometimes witnessed at the very onset of the disease
* Lebert gives the best statistics on all these points (p. 81).
700 GENERAL PATHOLOGY OF OANCEB.
(pp. 580, 585) ; and it is, probably, also exemplified in the later periods
of ordinary cases. Certain cases scarcely admit of explanation, on the
supposition that the first-formed cancer is, in any sense, the source of all
that grow after it : such, for example, as those in which a sudden rapid
multiplication of cancers takes place (p. 586) and those in which they
appear some long time after the removal of the first-formed growth.
The second method of remote multiplication of cancers, that of
conveyance by the blood, is sometimes visibly demonstrated, and may
almost always be assumed. I have spoken of cases (p. 673) in which
cancers so grow into veins, that we cannot doubt fragments may be
washed from them by the blood, and may grow wherever they come to
rest ; and I related one instance of osteoid cancer in which this almost
certainly occurred (p. 652). But, even when no such intra-vascular
growths appear, similar events may occur. In a case of primary can-
cer of the liver, in which the growths were all tinted with bright yellow
by the bile, I found numerous small cancerous masses of the same color
infiltrated in the lungs ; and the small branches of the pulmonary arte-
ries leading to these were filled with bright yellow substance, as if they
had been minutely injected with chromate of lead. The accidental color
of the cancer-materials, in this case, made their transference from the
liver to the lungs very evident ; but the same event is often, though
less plainly, traceable.
The transference of cancer-materials, with the blood from a cancer
already formed, need not be always seen to be believed. Its frequent
occurrence is made very probable by the many points of correspondence
which Dr. Walshe* has shown, between the dissemination of cancers,
and that of secondary abscesses after the entry of pus or other degene-
rate inflammatory products into the veins. The peculiar liability of the
liver and the lungs to be the seats of both these secondary diseases,
and the evidence that they are the organs in which foreign matters,
introduced into the circulation, are most commonly arrested, may nearlv
prove that they are, in all these cases alike, affected by materials brouc^ht
to them in the blood.
We need not assume that corpuscles of pus or cancer, or any kind of
germs already formed, must be thus carried for the multiplication or
dissemination of disease. A rudimental liquid, an unformed cancerous
blastema, mingled with the blood, may be as effectual as any germs ;
and must almost necessarily be assumed, in the explanation of cases in
which the dissemination takes place, not in the lungs or liver, but in
organs beyond them in the cour-se of the circulation.
The materials conveyed with the blood from the primary cancer must
be such as are capable of development, in order to the multiplication of
the disease. In the ordinary absorptions occurring in the process of
natural nutrition, and probably, also, in those that take place in the
* Nature and Treatment of Cancer, p. 106.
MULTIPLICATION OF CANCERS. 701
natrition of cancers, the venous blood carries away only degenerate or
refuse materials, such as we may assume would be incapable of develop-
ment. I have mentioned cases (pp. 580, 590), in which masses of can-
cer, probably thus degenerate, were absorbed, without any appearance
of consequent dissemination or other damage. We do not know what
leads to the removal of such cancerous matter as can be developed ; but
the necessity of some change in the ordinary process of absorption is
evident, and is the more worth studying because there are correspond-
ing similar differences in the effects of the absorption of pus and other
morbid products.
Such are the various means of numerical increase of cancers, — by
local inoculation of parts continuous, or in contact, with the primary
disease ; by extension, through a continuity of lymph or of blastema,
to the lymphatic glands ; by transportation of potent cancer-materials
with the venous blood ; by the cancerous condition of the blood becom-
ing, of itself, more intense. In certain cases, the increase may be ac-
complished by all these means at once ; the secondary cancers, also, as
soon as formed, become like centres, from which a tertiary formation
may be derived, as they were themselves derived, from the primary ;
and to all this it may be added, that, with lapse of time and failing
general health, all parts of the body are constantly becoming less
resistant of disease, and more appropriate for the residence of morbid
growths.
I have now to trace a general history of the retrogressive life of can-
cers ; of that which, as I said (p. 696), is signified in their various de-
generations and diseases.
The degenerations of cancer-structures are like those of natural parts,
and of other products of disease. Examples may be cited of every form
corresponding with those enumerated on page 84 and 259. (1) The
withering, or wasting and drying, of the structures is exemplified in
many scirrhous and epithelial cancers (pp. 532, 611); (2) the fatty de-
generation is so common that it might be hard to find a cancer in some of
whose corpuscles it does not exist. The granule-masses (" the mulberry-
cells") of cancers are hence derived, as they are from many more morbid
products. Hence, too, the " saponification" of cancers (p. 588), while
to the fatty degeneration, combined with more or less of withering, we
may ascribe the masses of substance, like tubercle, so often imbedded
in medullary cancers (p. 564), and the minuter spots and lines of soft
ochre yellow substance traversing scirrhous and medullary cancers,
like a "reticulum" (pp. 528, 588). (3) A calcareous degeneration is
observed in medullary cancers, and in osteoid (pp# 589, 649) ; and, pro-
bably, exists in many instances, mingled with the fatty degeneration.
(4) Pigmental degeneration is probably the essential character of me-
lanoid cancers (p. 643). (5) Thickening of primary membrane is, per-
haps, indicated in some of the cancer-cells whose walls appear simply
702 aBNBBAL PATHOLOaT OF OANOBB.
laminated (p. 612, Fig. 103, d). A liquefactiye degenefration may
ocoar in some of the softenings of cancers ; but, so far as I know, it
ensues only in connection with disease. (Compare p. 284.)
In the interpretation of degeneracy in cancers, we must again refer
to the two conditions of their life ; namely, the maintenance of the mor-
bid condition of the blood, add their inherent power of self-maintenance.
The snperyention of another diathesis may lead to the degeneration or
death of a cancer (pp. 550, 590) ; but this is extremely rare. A trans-
formation of diathesis may, I am disposed to believe, lead to the de-
generation of one cancer while it promotes the growth of one or more
others ; for there are cases of apparent metastasis of cancer, in which
the primary disease has withered, while secondary growths appear to
have increased.'*' But these cases, again, are too rare to be reasoned
from; and the usual course of events indicates that degeneration of can-
cer is, in the great majority of cases, an essentially local thing. For,
commonly, part of a cancer, or one mass in a group, degenerates, while
growth continues in the rest; and extensive degeneration is often found,
in cases in which the rapid progress of the disease has testified to the
full maintenance of the morbid blood. Hence the unhappy rarity of
the recovery from cancer. One that is degenerate or absorbed may be
as ineffective for harm as one that has been cut away ; but the consti-
tutional element and progress of the disease are as little affected by the
natural as by the surgical process of removal.
We cannot tell what are the local events that lead to this degenera-
tion ; but I suspect that the chief of them is the local obstruction of
bloodvessels by growths of cancer into them.
The diseases of cancers, like the degenerations, are essentially local
processes ; they are most apt, indeed, to occur in the enfeebled general
health, but they do not certainly indicate a decreased diathesis. It
may suffice to refer, for examples of most of the diseases, to those al-
ready cited (pp. 647, 690, &c.); but two require more consideration;
namely, softening and ulceration.
Some have believed that softening is almost a natural event in can-
cers, a change parallel with that in tuberculous deposits, and a neces-
sary precedent of ulceration ; while others, recoiling from the error of
this belief, have written of the softening of cancers as a rare and unim-
portant accident. The truth is about midway between these extremes.
There is no probability that (as some have supposed) the hard scirrhous
cancers ever become medullary by any process of softening ; a softened
cancer is very different from a soft one. There is no natural tendency
in cancers to become soft in their later stages : those of the oldest date
commonly retain, if .they do not increase, their original consistence.
Neither is softening a necessary precursor of the ulceration of cancers.
But any scirrhous or other cancer may be softened by degeneration, or,
* Cases cited by Walshe, pp. 110, 134.
DISEASES OF CANCERS. 703
more effectually and extensively, by inflammation of its substance. The
fatty degenerations of which I have just been speaking are usually at-
tended with a softening ; but the altered substance becomes drier and
more greasy than before ; it does not appear, in any degree, liquefied
(p. 529). That which is generally understood as softening of cancer is,
so far as I have seen, a more acute process, and the result of inflam-
mation of its substance. One may see it very well in the exposed
protruding growths of medullary cancers (p. 589) ; or in those parts
of them which lie just beneath inflamed portions of the integuments.
Sometimes, also, within scirrhous cancers that have rapidly enlarged,
with heat and pain, and redness of the superjacent skin, one finds large
portions liquid, or else very soft, as it were rotten, shreddy, and infil-
trated with pale, yellow, serous or puriform fluid. Sometimes such
softening has distinct appearance of suppuration in the centre of the
cancer ; but these cases (which have suggested the terms cancerous
suppuration or abscess) are, I think, most frequent in the secondary
epithelial and medullary cancerous afiections of lymphatic glands (pp.
691, 617).
If, as I believe, these softenings of cancer are the results of inflam-
mation, they correspond with the softenings produced by the same dis-
ease in natural parts (p. 276) ; they are the results of such defective
nutrition as always ensues in the proper textures of an inflamed part ;
and when pus is difi*used in the softened cancer-substance, the process
may be compared with ordinary purulent infiltration, which is always
attended with loss of consistence in the afl*ected part. With this view
the microscopic characters of the softened cancers agree.
Such softening as this, taking place within a cancer, generally leads
to ulceration, and to the discharge of the liquefied and degenerate mate-
rials, with whatever of serum, or pus, or blood may have been mingled
with them. This discharge is essentially similar to the opening of an
abscess ; but it is less regular, and the ulceration is quickly more de-
structive, and exposes widely the cancerous walls of the evacuated cavity.
I have already described both this and the other forms of ulceration
that may ensue in cancers (pp. 547, 586, 608). They are all, like the
degenerations, essentially local processes, and not indicative of any pe-
culiar advance or transformation of the cancerous diathesis. Ulceration
is, indeed, a feature of the later progress of cancer, and it is most likely
to occur in those whose health is most enfeebled ; it is, therefore, often
coincident with an exceeding intensity of constitutional disease ; but it
is not the consequence of such intensity. The amount of constitutional
disease is indicated by the growth, or by the multiplication, of cancers
rather than by anything which, like ulceration, implies imperfect main-
tenance of their structures ; and so we commonly see one part of a
cancer growing rapidly, while another is being destroyed by ulceration,
or many growing while one is ulcerating. Now the growth is, gene-
rally, the measure of the force of the constitutional disease; the ulcera-
704 GENERAL PATHOLOGY OF CANCER.
tion is the measure of the local defect of nutrition : and in these in-
stances we may watch, at once, both the progressive and the retrogres-
sive phenomena of the life of the cancer.
While dwelling on the constitutional origin of cancerous growths, I
must not forget their constitutional effects, — the changes in the blood
and other parts which are their consequences.
I said that a cancer adds a new element of disease to those that were
already in progress. And this may be said of it in consideration both
of its own life, and of the influence which its growth and changes have
upon the whole economy. If we assume a constant process of nutrition
in cancers, it cannot but be that the blood will be affected both by what
they take from it, and by what it derives from them in the process of
nutritive absorption. This latter source of change of the blood has
been too little considered, — the former, perhaps, too much ; for the
quantity of good nutrient material abstracted from the blood, in the
growth of a cancer, is probably very trivial, whereas what returns to
the blood is almost necessarily a morbid substance. It may be incapable
of development into cancer, but, unless it can be at once eliminated, it
must injuriously affect the blood. What change it works we cannot
tell; nor can we tell more of the later changes produced when com-
plete cancerous material is absorbed into the blood, or when secondary
cancers multiply in important organs, hindering their functions ; or when
ulceration ensues with pain, hemorrhage, discharge, and hectic, and all
the various signs of ruined health. When these things are added to the
still increasing cancerous condition of the blood, and when all, with
mutual influence, are in progress, they make a state so complex that
analysis seems impossible, and so various that no single or general de-
scription can be true. The general result is what is commonly called
the cancerous cachexia ; but (as I have said before) it should be called
the secondary cachexia, to distinguish it from the primary, which may,
though it rarely does, precede the formation of a cancerous growth, or,
in its independent increase, may far exceed the probable consequences
of the local disease (pp. 553, 692).*
The constituents of the secondary cancerous cachexia, I say, are too
numerous and complicated for analysis ; still we must always recognize,
in the later stages of the disease, the double source of the morbid
phenomena; namely, the progressive constitutional disease, and the
effects, direct or indirect, of the local disease. How nearly indepen-
dent the former is of the latter is proved by the results of removing
the local disease. The secondary cachexia and many of its components
may be, for a time, decreased ; pain and discharge, and all the local
* The induction of this secondary cachexia by the presence of a cancerous tumor, is well
illustrated by such cases as sometimes occur, in vvhidti after the removal of the tumor, the
general health remarkably improves, to fail again when recurrence ensues, and again to
mend after the second removal. See a case by Mr. Jon. Hutchinson, Med. T. & Gaz.,
July 16, 1853.
NOSOLOGY OF CANCERS. 705
accidents of the disease, may cease : but the average lengthening of
life is not great (pp. 556, 594, 634). The fact proves, not only that
the progress of the peculiar constitutional part of the disease is nearly
independent of the local part, but, also, that the constitutional part
generally contributes most to the fatal issue. However, in this, as well
as in the times and manners of dying, and the times of recurrence
after removal of the first growths, the difiFerence in the several forms
of cancer are such as should not be put out of sight by a general or
summary description : death is the common, and almost constant end
of all| but its circumstances should be studied separately in each.
In conclusion, let me add a few words respecting the nosological
relations of the several forms of cancer to one another and to other
diseases.
Here, as everywhere in pathology, it is diflScult to keep the just mean
of classification ; to avoid, on the one side, confusion ; on the other, too
rigid circumscription. The many features of resemblance in all the
forms of cancer, and the large general history which may be truly
written of them, might lead us to merge all minor distinctions, and
speak as of a single and uniform disease ; but it would be easy to show
that, if in this view we write of the general symptoms, progress, and
diagnosis of cancer, or of the history of cancers in any single organ,
we write vaguely, and are obliged to omit many points of importance,
for fear of contradictions. If, on the other hand, we look at contrasts
rather than likenesses, we might be induced to separate some forms, as
the epithelial and colloid, from the name of cancer, and to believe
that the remaining forms have no affinity with any other disease.
I suspect that the errors of such extremes as these (in all nosology,
as well as in that of cancers) come from our attaching too much mean-
ing to the terms that imply specific distinctions among diseases ; from
our proneness to think of them as if they meant the same as they do in
aoology. Now, there is no real correspondence between the two sets
of terms. A specific name, in zoology, usually implies that all to whom
it is given have origin from a common stock ; certain characters fixed,
and not changeable, beyond certain narrow limits, by variety of external
circumstances ; and circumscriptions, i, e, intervals of difiFerence be-
tween them and other species, which intervals are not filled up by varie-
ties or intermediate forms. Now in all pathology, there are, probably,
no such species as these ; and the terms implying the existence of genera,
species, and varieties of disease, mean only that the products of diseases
may be arranged, and the diseases themselves considered, in larger and
smaller groups, according to the number and importance of the charac-
ters which they have in common. Such terms do not mean that the
borders of each group of diseases are naturally circumscribed ; they
allow that the borders of each are confused with those of every ad-
jacent group.
I
BHAL PATIIOLOOY OP CAHC
With this meaning, I have adopted the ternis used in the fo
Lectures. The whole group of diseases included under the
like a generic name) of CaDcer or Cnrcinoiiia nre suffici
tinguished by the concurrence in them of all the charmctera
Qant tumors enumerated on pages 343-347. But thin
circumacrihed ; iu borders are everywhere overlapped by those of £■>
eases to which other names are given : there are no one or two clian»
ters pathognomonic of cancer and found tn it exclusively. Tlw fotfr
going Lectures have repeatedly illustrated this, especially in tfac ■>
counts of the recurring proliferous cysts (p. 3811), certain cartilaginoM
tumors (pp. 446,459), some of the myeloid (pp. 471, 510) sod iub-
mary glandular (p. 492), the remrring fibroid and fil)ro-uiicleM«d(Hi.
511, 517). and the rodent ulcers (p. 621). At the same time, thb vul
of definition in the assumed genus of Cancers has been exemplified, il
will be observed, chiefly by rare and exceptional cosm; bU the gnmi
facts collected in the Lectures have illustrated the Bufficieney of tb«
concurrent sign a of cancer for a ground of general classi&cadoa (iw
p. S47).
Among the different forms of cancer, I have already said (p. 6SS)
that there appear to be unequal degrees of difforcnec, which may httx-
pressed by speaking of three forms — namely, the scirrhona, me<liilLuy,
and epithelial — as species, and of the remainder as variclivi*. "f eaneer.
All that has just been said of the want of circumscription for tli« »••
called genus wiU, I need hardly say, be applicable to these saalbf
groups. But here is the chief point, at which, while avoiding loo wndt
precision, we must also guard against indifference ; for, as it hM bMa
wisely said, truth is more likely to emerge from error than fron eai-
fusion. The species and varieties of cancer, aa of other dJHe—M. it
not correspond with those of living creatures ; yet the differeneea of the
groups thus named are inconsistent with the theory of a single niidHac
ing disease ; and I believe the future study of the grounds of tbeM tfit
ferences will prove very fruitful both in knowledge and in prirtJwl
utility.
As yet we can only speculate upon them in questions. Do Acf
imply so many essentially and originally different morbid maleriaUl
or is there one material for cancer, one carcinogen, which, lik« an <»•
ganic radical, may form different yet closely allied coropoanila, in ill
combinations with the various substances provided by different bloody.
or different parts ? Is not this hypothesis more appropriate than ■!■
first for the less usual phenomena of transformation, such as I
described as occurring in the progress, succession, and hereditary I
mission of the cancerous constitution ? Is it inconsistent witb t]w
gradual fusion of the characters of typical cancer in those of other
diseases ?
TUBBRCLBS IN THB LUNGS. 707
LECTURE XXXV I.
TUBERCLE.
Onb often speaks of cancerous and other tubercles, meaning only
small knots or knotted masses of the specified morbid growths ; and of
tabercular cutaneous eruptions, meaning small circumscribed flattened
elevations or thickenings of the cutis. But when "tubercles," without
any specific designation, are spoken of, the word is always understood
to refer to little masses of a peculiar product of disease, the type of
which is found in the lungs as the essential anatomical constituent of
pulmonary consumption or phthisis. The same material as composes
the pulmonary tubercles is found in many different forms and organs,
and, wherever it occurs, is described as "tubercle," or "tuberculous
matter;*' and "tubercular disease," or "tuberculosis," is the usual de-
signation of the specific diseases of which the essential feature is the
production of this peculiar matter. •
Tubercle or tuberculous matter may be formed in distinct isolable
masses, around which the adjacent tissues are extended. These, which
are most frequent in the brain and, I believe, in the subcutaneous tissue,
may be like tumors, except in that they are not vascular, and, proba-
bly, have no inherent capacity of increase. But the most frequent
formations of tuberculous matter are in infiltrations of the natural tis-
sues, which infiltrations may be circumscribed, having definite, though
generally irregular, outlines, or diffuse, i. e, widespread and indefi-
nite.*
In the lungs (to which, on account of its exceeding frequency, we are
bound to look for its type) tuberculous matter appears, as Rokitansky
says, in two chief varieties, or in forms combining, or intermediate be-
tween them. These are generally distinguished as the "gray" and
the "yellow" tubercles; or the gray tuberculous granulations, and the
crude tubercles. It may also appear as a diffused tuberculous infiltra-
tion, either alone, or, more frequently, associated with the preceding
forms, or the changes consequent on them.
The gray tubercles appear as masses about as large, on an average,
as millet-seeds (whence their name of miliary tubercles), imbedded in
the substance of the lungs. They are usually from a quarter of a line
to a line in diameter ; and when the lung is cut through, so that its
elastic tissue can recoil and subside, they appear slightly raised on its
cut surface, and the finger may feel them as little firm resisting bodies
set in the lungs. They look round or oval ; but their borders are very
* The name, tubemulous infiltration, is commonly given to this dilfuse form alone ; but
in the miliary and other tubercles, even in the lungs, the peculiar materials are equally in-
filtrated among the natural tissues ; only, in these the infiltration occupies a defined area.
lal portiow m
irregular, w'ltli short outrunning proceases. They are gray,
parent, and modtraiely bright ; or, sometimes, are v«ry glistmibg, vilh
a greenish-gray "cat's-eye" tint. In the latter cose, tliey nuy Uifc
like little vesicles: but tUey arc always soliil. They may be diMreM,
I. e., placed singly, and with distinct, though small, intcrrals m tU
lung, or collected in groups. They occupy and involve in tbnr i^
stance the tissues of the lung, and are so conucoled, that portioif ti
these tissues always adhere to them when wo try to s«|
They may be easily broken and cruiihed, and, when tbtu
yield but little Buid.
The yellow tubercles in the lungs have the same general
relations as the preceding, but are commonly larger anil IvM Sr*,ud
are more often grouped so closely that, by fusion, they make np nMttf
uniform tubercular masses, half an inch or more In iliaraetcr. Tbfj
are usually pale yellow, or yellowish-white, opaque, friable, dry, diHit,
smearing the surface on which they are crushed. Very often, iW
color is varied with a smoky gray tint, partly due to intrinaic cbso^
and partly derived from the pigment of tlic lung involvwl by iban.
It has been generally considered, and, indeed, still is by maaj p-
ihologists, that the two varieties of pulmonary luberck" here detenM
represent two stages of the same disease; the gray substance bna^
after a time, changed into yellow. Rokitnnsky, however, hi>ld» ihil
they are always different substances ; and that, though they msT U
found, side by side, in the same lung, or may be mingle<l even in dx
same tubercle, yet the transformation of the gray into the yell"* rati-
stance never takes place. His names of "simple fibrinous" appUtdu
the gray tubercle, and " croupo-fibrinous" to the yellow, may inildy
that both the diO'erences and the affinities between the two fonu arf
comparable with those between the two chief varieties of inflaniiBatory
lymph (p. 233, &c.).
The minute structures of both the varieties of tuborcle are cMmtiaOy
similar ; and their distinctive characters (in the state in which iktj f-
pear to persist longest) are, the absence of blootivessels {exeqrt of Mcb
as are involved in the deposit and not yet wasted), and the defective^
developed or aborted state of the blastema and the corpuscles.
The blastema, or basis- substance, of a tubercle appear*, nnallj, ii
fragments or flakes of a moderately firm, clear, or dimly molecvhr f^
stance, swelling and made clearer by acetic acid. It ia most
in the gray tubercle, most molecular or dotted in the yellow. It bai
filamentous appearance, no trace of developing nuclei or fibres.
The corpuscles held together by this substance, arc {a) abowlsnl
nutest molecules, granules, and oil-p&rticies of various bat iisvaBf
email siee ; all these being extremely predominant in the yellow tatw^
cle ; (b) nuclei or cytoblasts, of various shapes and apparent •tmcHnk
but all degenerate or defective ; some glittering, hard-edged, wrinkk^
and withered ; others granular ; few or none with dtattnct aoeleuKf
THEIR CHIEF F0KH8. 709
(e) nucleated cells, similarly miBshapen, withered, or granular ; {d) cer-
tain componnd cells described below.
Mingled Tith these, and varying according to the situation and cir-
camstances of the tubercles, numerous other, but accidental, substances
are often found : namely, (a) the involving and disintegrating structures
of the lung ; membrane or elastic fibres, degenerate epithelial cells of
the air-vesicles or minute bronchi : (£) various and usually degenerate
products of inflammation from the adjacent parts, granule-cells and
maases, pus-cells, &c. : (c) molecules of calcareous matter, or of pig-
ment, and crystale, especially of cholesterine. ,
Such are the ordinary constituents of pulmonary tubercle, and the
ehrivelled nuclei and imperfect celts, being usually the most abundant
Hid distinct, are called tubercle-corpuscles. Similar materials are found
composing the tuberculous matter in other parts. In the lungs, accord-
ing to Virchow* and Schroeder van der Kolk,t their origin may, in an
earlier stage, be traced in changes of the epithelial cells of the air-
vesicles.
The adjacent copies of the drawings by Schroeder van der Kolk may,
with his description of them, sutGce to explain the process.
" The margin of an air-vesicle, from which most of the tubercle-cells
ftre removed, is shown at a a a ; that of another adjacent vesicle, nearly
filled with tubercle-cells, at J 6 b; and that of a portion of a third vesi-
cle, clear of tubercle-cells, at c. At d the still iinalFectcd wall of the
Mr-vesicle is shown covered with epithelial cells of various sizes, and
containing nuclei, oil-drops, and granular matter. In the middle and
ftt the end of the same vesicle are some cells of darker tint ; they are
no longer flat, but filled with some material, and thereby more or less
* Wflnbuig VeihBmllunBen, i, bl.
f Over den Oorapiong en de Vorming van TubercuLs Pulmonum : NederlBnilach, Lan-
gM, I8S2.
t Fig. 116. Very thin Kclion of ■ porlion of lubeiculoui lung, described in the text.
]C^niaed4a0timM.
710
TtrBSRCLBS IK THK tOireS;
I
swollpii or spherical ; they are epitheliiU cells more or I«w
with fluid, and detached, and, aa the eeriea of them shows. tbejMfr
stantly enlarge. In the next vesicle, i, these cells hart- tMTcnmvBBtfc
larger, and are cloiiely udhcrent. It is observable thai the largMtottl
commonly lie in the middle of the cavity of the air-cell : the Iwjjer vt
mostly filled with many nuclei ; in the amnller there is but on*."
•' It is thus evident, that these cells, which fill the air-Teejcle» 1114
make up the tubercles, are nothing else than epithelial celU, which f«tn
by imbibition of plastic matter, enlarge, and arc detachci] from the »l
of the air-VL'sicle. The cells which are placed in the tuiddle »f the vrn-
cle are, thus, the oldest, i. e., the first removi-d from the wkHs, ih«
longest exposed to the infiuence of the surrounding fluid, and iherrfoi*
the largest.* They are all filled with granular matter and miBioc oil-
spherules, and in the larger an increase of nuclei has taken place."
"If tubercles be examined in a somewhat further advancr^ ttaft^
when they show more tendency to softening, the larger celts joat dl>
scribed are found in much letw (jambtitr. Mid it
Fig. UT.f place of them the air-vesicle is filled wiih naallcr
I cells [and nuclei]. Among these, howorer, mM
_^ larger cells appear (as in Fig. 1]7, a) coittauia|
00^^^ t^^ smaller cells or nuclei, which are complrUly &$
^V (^10^ those that are free {b b) ; so that there ctt U
VF doubt but that, ill this stat«, the larger
are dissolved or burst; and the smaller'
free." These smaller celts and nuclei set freeare what bare
rally described as the tubercle corpuscles; »(id, as 1 have ali
the tuberculous deposits, after the earliest periods of their fr
may appear to contain no other formed corpuscles besides them-t
* In Ihe Collpge MuMiim, No. UUT, i> Uie lung of ■ BcnlOTong (Anllctit BmX
whioh tliows, (ppatFoily very well, tbu pia|ET«uive acaumulstioii of mlieraiitoai
l>oni ihe wulla lo llie cenim of ihe air-wlU,
t Fig. 1 1 7. Tubercle-rnrpUKlei : tnagniflnl 4'Ju limei and •)«cnlied in lb* Urn. <
rmm ScbroeJer van dec Kalk,
i In BO elaborale paper in Itie Br. & For. Mnl. Chi. Rev.. April. IMi. On dw Di
ment or Tubercle, Dr. C. R. KhI! iiaies thai tb? Ibnnatioii of tiibaicle in Ui*tnnf>a<
panied and preceileil by fully (leKciieratiiui of many o( lbs rpithaliUm^eli* of tk* ■ii>-«<
He liKdci upon llie large, mnny-nuclenied celli oi modiflail npilligliiiOHwIla, hai itoa
Van iler Eolk tecnu lo do, limit Ihem la llie cenlral |»rt> of lbs oivkiM rt ih» ai
H* Matea thai thvy may be found of ilic largcii uze and Mmlalniiig ibelr laryiM •*«
nuclei, wbiia olowly adliemnl ID lli« wall of tbo air-Keaiclc. Nnlhor don be ^naM
llie free lulwrcle corpuauleii are wilely derived from tlie nuoki vf lh« tmrfm erila, ma I
liio butiliiiK nf Ihe walla, bul thai llie prupnr (uberule cntfivtclv are imailr It
from ihe plasma aiudeil into ibe lir-vpiicle*. Viic
viewi thai the nwpuiclei of pui and cancer are developed Irfm Ihi* |
nuclei of tbe leitiirrt, haa, by carrying out the nn
velojnneiil of tubercle oorputrlei u prollfeniUiig cbanget Ir
liuue of ihc pan in which ihe luberele arise*. (Cell. Path., t-eolnrn X
bu illuHrsted in hit Alln> (Taf. iixvi, flg. I) Ihe devetopmr
noati ve-linue corpuacle* in pulmunary lubeccaloni;
In a icceni paper ttt V'uctuiw'k AichU (uiv, p. 571), BindDuHb I
THEIR CHIEF FORMS. 711
• Now the most peculiar character of tuberculous matter which these
descriptions illustrate, is its early degeneration, its abortiveness ; it is
shown as a material which, after proceeding for a little way in the ac-
quirement of organic structure, then stops in its course, recedes, and
degenerates. This is evident, at once, in the shrivelled or granular
structure of the set-free nuclei and cells ; and the later changes are
still further degenerative ; all prove tuberculous matter to be not only
yery lowly developed, but generally incapable of development.*
These later changes may be again illustrated by the examples of
pulmonary tubercle, and, according to Rokitansky, may, like the dif-
ferences of the original deposits, be compared with the degeneration of
the fibrinous and corpuscular or croupous varieties of inflammatory
lymph (pp. 268, 262).
(a) The withering (obsolescence, or Verhornung of Rokitansky) is
the peculiar degeneration of the gray tubercle in the lungs. It loses,
herein, its lustre, becomes dry, dense, and hard, and shrivels into a
shapeless, or indistinctly fibrous, little mass. The change is sometimes
associated with a calcareous degeneration of the tubercles, and often
with corresponding changes in the part of the lung in which they are
imbedded, and which becomes dry, shrivelled, and dark with pigment.
(6) The calcification, or calcareous degeneration, occurs in the yel-
low, and in the mixed, varieties of the tuberculous matter. When
achieved, it may be taken as an indication, like the withering of the
gray form, that the tubercles are not longer subject to change : that
they are, generally, obsolete, and without influence on the tissues around
them. It may occur both in recent yellow tubercles, and in such as
are already softened ; it is exactly comparable with the calcareous de-
generation of inflammatory lymph and pus, and is usually associated
with withering and pigmental degeneration of the surrounding substance
of the lung.
(c) The softening or liquefaction of tuberculous matter is, also, ob-
served only in the yellow and mixed varieties. Though more studied
in tubercle than in any other morbid product, it is not peculiar to it,
but is probably analogous with many other liquefactive degenerations,
and may be in all points compared with that of inflammatory lymph
of formation of the cells of miliary tubercle in a case of acute hydrocephalus. He found the
various ramifications of the arteries of the pia mater studded with numerous millet-seed like
granules, and he traced the development of the cells, of which these granules were com-
posed, from the nuclei of the external coat of the arteries to which they were connected.
* An exception to this statement must be made, for certain ca?es, in which one part of
what seems to be a uniform material is developed into, or towards, false membranci and
another part passes through the degenerative changes of tubercle. Such an event may be
seen, according to Rokitansky (vol. i, p. 409), in the tuberculous disease of the peritoneum
and other serous membranes. Schroeder van der Kolk represents (as in fig. 116 b) fila-
ments of rudimental new-formed tissue, which, he says, are sometimes found among the
cells of pulmonary tubercle. In tuberculous peritonitis, the portion of material developed
into fiilse membrane may become vascular, and may make a seeming, though not a real,
exception to the rule of the non vascularity of tuberculous matter.
712 TUBERCLES IN THE LUNGS:
(p. 259). It constitutes the so-called tuberculous suppuration, and pre-
cedes the formation of tuberculous ulcers and cavities.
The process of softening usually commences at or near the centre of
the tuberculous mass ; in the part of it which, we may beliere^ beiag
most remote from blood, is least able to maintain itself in eren racli
low development as it may have reached. The central softening is that
which is spontaneous and normal in a tubercle : it may be regarded u
a natural degeneration of the morbid substance ; but any collection of
tuberculous matter may also be softened, at its periphery, by the min-
gling of liquid products of inflammation in the adjacent tissues. The
two processes of softening may appear similar, and may coincide, bm
they are essentially distinct: one is spontaneous, the other aecidenul:
in the one the liquid material is the very substance of the tubercle, in
the other it is derived from without.
In the proper softening of a tubercle one sees its central part become,
first, soft, so that, when cut across, it looks cracked and crumbling,
and may be pressed away from the surrounding firmer part, leaving a
little central cavity. In further stage of the degeneration, it become*
liquid, like thin pus, with flakes or grumous particles in a pale yellow-
ish turbid fluid ; and as the change makes progress, the whole tnberca-
lous mass may be reduced to the same liquid state.*
The liquefied tuberculous matter consists of the lowest of the corpus-
cular materials already enumerated (p. 708) ; but they float now in a
liquid containing more abundant molecules and particles of uily an-i
calcareous matter. The usual sequence of the liquefaction is tin* "i:--
charge of tlie liquid, by ulceration of the tissues inclosing it ; but if the
liquid be retained, it may undergo further changes, which uuiy bt» cm-
pared with those of the retained contents of chronic al>scosse.H \\k -T-'ii.
The chief are, that its fluid parts are gradually absorbed, and its falTv
and calcareous matters increase, till it becomes a dry, greasy, crum-
bling, or gradually hardening, mortar-like concretion.
Tiie discharge of a quantity of liquefied tuberculous matter, by ul-
ceration through an adjacent bronchus, or through the intrgiiment> ff
a subcutaneous tuberculous lymphatic gland (for example), leaTe?> a
cavity, vomica, or abscess ; when the discharge takes place from singlt:
small tubercles, such as form beneath the surface of the mucous mrm-
braiie of the intestinal canal, an ulcer remains; and these are, severallv,
sufficiently peculiar in their characters to be known as the tul>erculott*
cavity, and tuberculous ulcer.
The ulceration eff'ecting the discharge is usually the conscM|uence of
inflammation in the tissues over the tuberculous matter, and resomMe*
that for the discharge of common pus. By similar inflammatorv ul-
ceration of its boundaries, the tuberculous cavity or ulcer may be in-
* StK'h ciinngfs may bo sren better, 1 think, in the tubercles in tho spleen xhmn lo ibu«r
in any other part: Mus. St. Bartholomew's, Ser. xiii, 2, 3.
TUBERCULOID SUBSTANCES. 718
larged: but more generally, and more normally, its enlargement is due
to the formation and discharge of fresh tuberculous deposits adjacent
to it. This may be best seen in tuberculous ulcers of the intestines ;
but the same process occurs at the cavities in such parts as the lungs
and lymphatic glands. At the borders and bases of the cavity or ulcer
one may often find small secondary tubercles, which, following the same
course as the primary, liquefy, and are discharged into the cavity, or
on the surface of the ulcer, which they thus increase by adding their
cavities to it. Other tubercles, again, may succeed to these, and pass
through the same changes ; and when many cavities and ulcers are
thus simultaneously enlarging, they come into collision, and two or
more are fused into one of sometimes vast dimensions.
In these changes, the tissue involved in the tuberculous deposits
(whether primary or later) soften, and are disintegrated and discharged
with them. There is thus, always, a loss of substance in the affected
part, coextensive with the tuberculous cavity. But, the bordering
tissues, if not tuberculous, may be infiltrated with organizable inflam-
matory lymph, which, in its development, may form a tough boundary
to the cavity or ulcer, and, if fresh tuberculous matter be not deposited
in it, may lead to complete healing.
Before illustrating the foregoing general account of tuberculous mat-
ter, and of its principal changes, by some of the instances which are
chiefly interesting in surgical pathology, it may be well to speak of
some affections which have an apparent or real aflinity with it.
Degenerative changes, similar to those which ensue in the lowly
developed materials of tubercle, may produce a similar appearance in
other materials, — especially in those which consist of cells, or rudi-
ments of cells. Thus, it is common to find, in medullary cancers, and
more rarely in others, portions of yellow, half-dry, crumbling, and
cheesy substance, so like tubercle that, with the naked eye, they can
hardly be distinguished from it. The cancers in which they occur have
been described as mixtures of cancerous and tuberculous matters ; but
the microscope finds that the tuberculoid, or, as M. Leber t calls it, the
phymatoid, material in them consists of cancer-corpuscles withered,
with fatty and calcareous degeneration, and mingled with molecular
and granular matter. By similar degeneration, material like tubercle
may be found in cartilaginous, rudimental fibro-cellular, and probably
other, tumors. In all these instances, the microscope may usually
insure a just diagnosis, and may prove that the tuberculous appearance
is only due to a withering and a fatty degeneration of materials that
have nothing but their, degeneration in common with true tuberculous
matter.'*'
* Virchow (Wiirzburg Abhandl., B. i, ii, iii) had proposed to speak of the change, in all
these cases, as a '* tuberculous metamorphosis," or " tuberculization," and was, of course,
misunderstood, as if he had implied that every material may become tuberculous matter.
46
714 TUEJBEOULOID BUB8TAN0BB.
Greater diflScuIty of diagnosis exists when, throngb similar degenen-
tion, inflammatory lymph assmnes the appearance of tuberoolous mat-
ter. It does so, sometimes, in chronic inflammation, or, when acute
inflammation has subsided, in lymphatic glands, in the testicle, and, I
believe, in some other parts. So, too, if the pus of chronic abscesses
or other suppurations is not discharged, it may gradually dry ; and u
its corpuscles wither, with fatty and calcareous degeneration, it mty
assume an appearance very like that of tuberculous matter. And, in
all these cases, the resemblance may extend equally to the microscopic
characters ; so that there are, I believe, no signs by which degenerate
lymph or pus may be, in all cases, distinguished from ordinary tuber-
culous matter. When, as in the cases cited on page 268, the lymph-
cells have been developed and elongated before their degeneration, they
may be known from any corpuscles of tubercle; and the many-nucle-
ated cells in tuberculous disease may be distinguished from the ordi-
nary products of inflammation ; but neither of these forms may exist,
and then I believe that a distinction of degenerate lymph from tubercle
may be impossible. Certainly, it is often very diflScult to say whether
the yellow, dry, and cheesy material, found in chronic enlargements or
suppurations of lymphatic glands, should be regarded as tuberculous
matter, or as withered and degenerate lymph vor pus produced by in-
flammation. The same difficulty may exist in the similar affections of
the testicles; but in these, more than in the case of the lymphatic
glands, we may be extremely doubtful of any material being really tu-
berculous, if it be found in them alone, and not at the same time in
other parts of the genital apparatus, or in the lungs. Similar difficul-
ties may exist in the diagnosis between tubercle and some instances of
chronic pneumonia.*
Thus, then, there are not a few cases in which materials like those
of tubercles are found as results of diseases that are not tuberculous ;
t. e. that are neither coincident with, nor according to the type of,
tuberculous disease in the lungs. And the difficulty hence arising is
increased by this : that both tuberculous products, and the varieties of
degenerate and withered lymph and pus, are especially frequent among
persons of the " scrofulous** or "strumous" constitution; so that the
degenerate lymph and pus are often described as " scrofulous matter;"
and "scrofula** and "tuberculous disease** are often regarded as the
same disease.
It is, I fear, impossible to clear the confusion arising from the inter-
changing uses of these terms, or to define exactly the cases to which
they should severally be applied ; but where definition of terms is im-
He suggests, now, that the change by which so many essentially different things may be>
come " cheesy," should be called "the cheesy metamorphosis."
* Vircliow has written fully on this point ; and a clear statement of hit and others'
opinions, respecting the different forms of pulmonary phthisis, is givea by Dr. Jenner in the
Br. and For. Med. Chir. Reyiew, Jan., 1853.
SCROFULOUS OR STRUMOUS DISEASES. 715
possible, the next best thing is an understanding of their meaning
according to general usage. "Scrofula,*' or "struma,** then, is gene-
rally understood as a state of constitution distinguished, in some mea-
sure, by peculiarities of appearance even during health, but much more
by peculiar liability to certain diseases, including pulmonary phthisis.
The chief of these " scrofulous*' diseases are various swellings of lym-
phatic glands, arising from causes which would be inadequate to pro-
duce them in ordinary healthy persons. The swellings are due, some-
times, to mere enlargement, as from an increase of natural structure ;
sometimes to chronic inflammation ; sometimes to more acute inflamma-
tion, or abscess ; sometimes to tuberculous disease of the glands. But,
besides these, it is usual to reckon as " scrofulous** affections certain
chronic inflammations of joints; slowly progressive " carious" ulcera-
tions of bones ; chronic and frequent ulcers of the cornea ; ophthalmia
attended with extreme intolerance of light, but with little if any of the
ordinary consequences of inflammation ; frequent chronic abscesses ;
pustular cutaneous eruptions frequently appearing upon slight affec-
tion of the health or local irritation ; habitual swelling and catarrh of
the mucous membrane of the nose ; habitual swellings of the upper lip.
Now these, and many more diseases of the like kinds, are, amongst
us, both in medical and in general language, called scrofulous, or stru-
mous ; but, though many of them are often coincident, yet it is very
diflScult to say what all have in common, so as to justify their common
appellation. Certainly they arc not all tuberculous diseases. Little
more can be said of them than that, as contrasted with other diseases
of the same forms and parts, the scrofulous diseases are usually dis-
tinguished by mildness and tenacity of symptoms : they arise from ap-
parently trivial local causes, and produce, in proportion to their duration,
slight effects : they are frequent, but not active. The general state on
which they depend may be produced by defective food, with ill ventila-
tion, dampness, darkness, and other depressing influences ; and this
general state of constitution, whether natural or artificially generated,
is fairly expressed by such terms as " delicacy of constitution,** "gene-
ral debility," " defective vital power,** " irritability without strength.**
Such terms, however, do not explain the state that they express, for
they all assume that there are, in human bodies, different degrees of
vital power, independent of differences of material ; which is at least
not proved.
Such is the vagueness of " scrofula," and of the terms derived from
it, as commonly used in this country. They include some diseases
which are, and many which are not, distinguished by the production of
tuberculous matter. It has been proposed, but I doubt whether it be
practicable, to make "scrofulous" and "tuberculous" commensurate
terms : as at present generally employed, the former has a much larger
import than the latter. The relation between the two is, that the
^* scrofulous" constitution implies a peculiar liability to the tuberculous
716 TUBERCULOUS DISEASE OF LYMPHATIC GLANDS.
diseases ; and that they often coexist. Their differences are evident in
that many instances of scrofula (in the ordinary meaning of the word)
exist with intense and long-continued disease, but without tuberculous
deposit ; that as many instances of tuberculous disease may be found
without any of the non-tuberculous affections of scrofula ; that, as Mr.
Simon has proved, while the disease of "defective power" may be ex-
perimentally produced in animals by insuflScient nutriment and other
debilitating influences, the tuberculous diseases are hardly artificially
producible ; that nearly all other diseases may coexist with the scrofu-
lous, but some are nearly incompatible with the tuberculous.
Now, whether we disuse, or still use in its vagueness, the term scro-
fula, we may make a group of the " tuberculous" diseases, defined by the
peculiar morbid product, of which I have described the chief characters.
Only, at present, we must be content, I believe, to be sometimes in
doubt whether the substance found in lymphatic glands, and commonly
known as scrofulous matter, be truUy tuberculous matter, or degenerate
lymph or pus.
The Lymphatic Glands, among the parts specially studied in surgi-
cal pathology, hold the first place in liability to tuberculous disease.
In children, they are, even more often than the lungs, primarily
affected ; in adults, they are next to the lungs in the order of fre-
quency ; and in all ages, whatever part becomes tuberculous, the lym-
phatic glands in relation with it are apt to be similarly affected.
The glands most often primarily tuberculous are the bronchial, mesen-
teric, cervical, and lumbar. Their state, previous to the tubercular
formation, may seem healthy ; or they may be simply enlarged ; or
signs of inflammation may precede and accompany the deposit. Roki-
tansky says that, in some cases, the tuberculous matter, as in the gray
pulmonary tubercles, appears in small round masses of grayish sub-
stance. But its far more frequent appearance in the glands is, like
the yellow, pulmonary tuberculous matter, in the form of roundish or
irregular deposits of yellowish, opaque, half-dry, cheesy, crumbling
substance. Such deposits are infiltrated among the proper textures of
the glands. At first discrete, and contrasting strongly, both in sub-
stance and in color, with the unaffected portions of the gland, they
gradually increase, till they may completely displace the natural struc-
ture, with its bloodvessels, or leave only a thin outer layer of it in-
closing the yellow mass which they form. By the increase of the
tuberculous matter, as well as by the swelling of their proper textures,
the glands are usually enlarged ; they may acquire even an enormous
volume, and, when whole series of them are affected, may construct
great lobed and nodular swellings. In all cases, however, the several
glands maintain a kind of independence ; so that one may enlarge while
others diminish, and one or more may inflame or suppurate ; while, in
others, the tuberculous matter remains stationary, or retrogrades.
TUBKRCULOUS DISEASE OF LYMPHATIC GLANDS. 717
The minute structures in tubercle of the lymphatic glands are essen-
tially similar to those described from examples in the lungs : and Yir-
chow'*' has found that, in the first stage of the process, there is an endo-
genous increase of nuclei within the elementary structures, similar to
that which I have described after Schroeder van der Kolk. The same
softening and liquefaction, also, as in the lungs, is prone to ensue in
the lymphatic glands.
The softening is usually central, and thence extending may affect the
whole morbid substance. The result of the change is not a homoge-
neous liquid ; but, rather, a mixture of thin, turbid, yellowish- white
liquid, and portions of soft curd-like, cheesy substance, like fragments
of tubercle softened by imbibed fluid. To these are commonly added
the liquid products of the inflammation of whatever remains of the
gland-substance, or its capsule, and the surrounding parts. The mix-
ture constitutes the tuberculous, or, as it is generally called, scrofulous
pus, of which the chief characters, as distinguished from those of ordi-
nary inflammatory pus, are, that it has an abundant thin, yellowish,
and slightly turbid liquid, with white, curdy flakes that quickly subside
when it is left at rest.
The liquefaction of the tuberculous matter in the glands usually leads
to its discharge ; and this is effected, in the case of the cervical and
other similarly placed glands, by ulceration, which differs from that for
the opening of common abscesses, chiefly, in being slower, and attended
with less vivid and less concentrated inflammation. There is, therefore,
less disposition to point : the skin is, proportionally, more widely under-
mined, more extensively thinned. Thus gradually, by thinning and in-
flammation, deprived of blood, the inflamed skin over the tuberculous
gland whose contents are liquefied, may perish, and form a dry parch-
ment-like slough, very slowly to be detached. More commonly, how-
ever, one or more small ulcerated apertures form in the skin, and let
out the fluid. If the undermined skin be freely cut, its loose edges are
apt to ulcerate widely ; if it be only punctured and allowed to subside
gradually, it usually contracts and recovers its healthy state.
The cavity left by the discharge of the liquefied tuberculous matter,
and of the fluids mingled with it, ipay heal up like that of an ordinary
abscess; but it does so slowly, and often imperfectly, inclosing portions
of tuberculous matter, which soften at some later, and often at some
distant, period, and lead to a renewal of the process for discharge.
However, such retained portions of tubercle, or even the whole of what
has been formed, and perhaps liquefied, in a lymphatic gland, instead
of being discharged, may degenerate further, and be absorbed ; or may
wither and dry up into a fatty and calcareous concretion. Such chalky
masses, even of large size, are frequently found in bronchial and mesen-
teric glands that have been seats of tuberculous disease in childhood ;
♦ WUrzburg Verhandlungen, i, 84.
TDBBBCDLOCS OLCBRB OF TUlt tXftOVWWW
and Bimilar material, but nsu&lly in smull fragiuenta, is ofteti d
fi'om healing tuberculous absceflsea in the neck.
Whetber by bcaling after discbarge, or bj calci&cation of the i^H
tained tuberculous matter, the recovery from iby [irimnry tubcTcolmi
disease of the lymphatic glands is often complete and pcrmBontL IW |
original substance of the gland may be wholly destroyed ; or portNoa |
of it may remain indurated and fijccd elusely tu the scar or tfac talc^ J
reous concretion.
I am not aware that tubercle is ever seen, primBrily, in I;
vessels ; but it may be often traced in those of the iotcKtiaes an
tery that are in relation with tuberculous ulcers iuvolving the ■
and subperitoneal tissues.
I am not aware that tubercular iluposits have been proved
origin of the so-called scrofulous ulcers of the iiiicgument ; I
they are so is highly probable, seeing that such ulcen aomcttmi
vene at the openings for discharge of liquefied tubercle from ljwpk«lit
glands, and that, in many characters, they remarkably resenbb
tuberculous ulcers of the mucous membrane of the intestines.
The ulcers for which we may suspect a truly tuberculotu origm
most frequent in the neck, at the aidea of the face, at the u|i|>er part rf
the chest, and on the arms. Thoy arc sometimes pfocetted by thr fot^
mation of one or more small oval masses of firm substance in tlie
cutaneous tissue : these, passing through tlic usual change* of a
rating tuberculous glands, discharge themaelves; and tbe ■Joerati—
extends from the aperture of discharge. But, more often, the akcO
commence in patches of skin which, with the subcutaneous tisaae, !»<«
appeared for some days or weeks, inflamed, thickened, and utijzlitly !»■
ilurated. Central softening and liquefaction ensue in titeae ; the mtia
is gradually undermined, and then ulcerates, letting out a anuill qoaar
tity of thin, flaky, and turbid fluid, like that of liquefied tuberde. Tta
ulcers thus formed have generally destroyed the thickness of the
They arc of various shapes ; most often elongated oval, but aomi
round, or sinuous; more rarely annular, or crescentie; very nR];f
quite regular in shape. Their margins are usually (if tbey ar*
quickly extending) undermined, rounded, thickened, and nt)C4|aa]. Ite
skin upon and around their margins is pale ro8i>-pink; or tends, sceori
ing to the activity or torpor of the disease, towanln florid rednew, m
palo livid hue. Their bases are unciiual, often nodular, or tul
pale, with unequal or succulent granulations; they yield n tbin, ti
whey-like fluid, which may concrete in scabs, and Bometimas
the parts on which it lies. They have no proncnraa to extend
depth ; neither do they extend widely, unless acute
venv at their boundaries ; rather, their tendency is to remain long Ma^
tionary, or partially healing; or, while some are healing, otliefi Bsf
be progressive.
TUBERCULOUS DISEASES OF BONES. 719
The scar formed in the healing of these ulcers is peculiar, resembling
that of the healed tuberculous ulcers of the mucous membrane of the
intestines. It is formed of very tough tissue, which remains long fixed
to the subjacent structures, and of which the surface is generally
colored with vascular congestion, seen through the thin covering of new
cuticle. But, chiefly, the surfaces of such scars are deeply seamed and
wrinkled ; or have prominent hard ridges that tend towards their cen-
tres, or across their axes. The cutis that surrounds the ulcers is very
much contracted in the formation of the scars : and both in this re-
spect, and the abundant tough tissue constructing them, they may be
likened to the scars following burns.
Among the Bones, tuberculous disease affects most frequently those
of spongy cancellous tissue ; such as the tarsal and carpal, the verte-
brae, the phalanges, and the expanded articular portions of larger bones,
especially of the femur, tibia, humerus, and ulna. When it affects
bones that are arranged in a group or series, it is usually found in many
of them at once. Thus, several vertebrae, or several carpal or tarsal
bones, are commonly at the same time tuberculous ; yet not often so
equally, but that one of them appears first and chiefly diseased ; while,
in those gradually more distant from it on either side, the tuberculous
deposits are gradually less abundant. In like manner, the parts of
bones that act together in a joint are, usually, at the same time tuber-
culous.
Rokitansky says that gray tuberculous matter may be found, about
tuberculous suppurations in bone, in the form of granulations seated in
the medullary membrane. The usual appearance is that of yellow, soft,
cheesy deposits, or infiltrations of tubercle. The infiltration may be
either circumscribed or diffuse : and, in these differences, generally cor-
responds with the similar varieties in the lungs ; especially in that,
usually, the circumscribed infiltrations take place with scarcely any
signs of inflammatory disease, while the diffuse are preceded and accom-
panied by all the signs and effects of slowly progressive inflammation
of the bone.
In the circumscribed infiltrations, the tuberculous matter usually
forms round, or oval masses, which are imbedded in cavities in the in-
terior of the bones. At these cavitifes, several of which may exist near
together, the normal textures of the bone appear to be disintegrated or
absorbed, just as those of the lung are during the infiltration of the
tuberculous matter among them. When the liquefaction of the tubercle
takes place, a similar imitation of the formation of cavities in the
lungs is noticeable. The usual thin puriform fluid is produced, and is
often mixed with little fragments of bone. The bony cavity including
it commonly becomes lined by a thin, smooth, closely adherent mem-
brane,— the product, apparently, of ordinary inflammation. Appear-
ances are thus attained, especially in the bodies of vertebrae, like those
TaBsaouLocs diskasss or bohbs.
of numerous small chronic abfceases in bonea : itiiil aimiUr ekvitiaftHftj
be found between tbe bone and periosteum, when the tubereuli
has been formal between tbem, or has inclmled the eurfttce of
in its infiltration. The H'lntd contents of the cavities any be
through narrow apertures in the walls of the bon«, or othcr
ing parts; hut, commonly, a more diffuse inflammatory or ti
formation ensues, destroying both the walls gf the cavities
boundaries.
The diffuse infiltration of tuberculous matter in bone maj be tU
form assumed from the first, or it may siipi-rvene on tbt^ praevdiBg.*
The deposits observe no definite shape: they fill the caooellova •paos
in the bone, displacing the medulla, and cither leaving the rmorwi ta
sue entire, or softening and disintegrating it, so that small tnffuitt^i
or larger seijuestra, appear mixed with the crumbling tut * ~"
abundant deposit of tubercle, and the fulness of the veaaeU
flamed and softening bone, make the swelling in thi« Tona
siderable than in the preceding; yet it is rarely, if e
liquefaction is attended witif larger and more destructive, thonj^h ilo«,
ulceration of the bone ; and is followed by discharge of the flnid 1^
gether with products of inflammation, through many «p<:rttinM,or&OM
a widely ulcerated surface. The bono bounding such olcentiwi %
moreover, commonly inflamed, if not tuberculous ; and thus the nkcr^
tion may constantly make progress in depth and width, imiutiag tb«
types of tuberculous ulceration already described, in that tbe deMne>
tion is of twofold character: due partly to secondary fomatiooi nd
liquefactions of tubercle, and partly to continued bordering m0aBii»-
tion.
The changes produced by circumscribc<I tuberculous dopoMts m b<M
are, comparatively, seldom seen ; for tbe disease is of slow progrcM,
and rarely leads to death, or amputation, before the more diffiue uloer*-
tion has supervened and destroyed its characteristic features. The Ht-
fuse disease is therefore that which has been most studied. Mid which
has supplied most of the examples of "scrofulous caries," " Pott's di»-
ease of the spine," "Pffidarthrocace," &c. it is this, alM, which i*
chiefly attended with suppurations, or, perhaps, tuberculous depontSt
in the neighborhood of the diseased bone.
The tuberculous diseases of bone are, comparatively, rarely bnled.
Mr. Stanley has well shown that the completely ouraMe om* rf
"scrofulous" disease in bone are those in which "the cbaogea hat*
not passed beyond tboiie of simple inflammation :" i. e., of sadi iala**
mation as commonly precedes the diffuse deposit of tubercle. WbtM
tubercle is deposited in bone, its usual course is, as in other parti, atij
degenerative: it may liquefy, or calcify: it is, probably, D«v«r ngui-
n,N(».S&4-3: uli««M<tflL
AFFINITIES OF TUBERCULOUS DISEASES TO CANCER. 721
ized or absorbed. Calcareous concretions, that had their origin in tu-
berculous matter, may be found imbedded in or upon bone, inclosed in
indurated osseous or periosteal tissue ; but they are, I believe, ex-
tremely rare. Healing of tuberculous cavities and ulcers in bone is
less rare. No new bone may be formed ; but the membrane lining a
cavity may become thick and tough ; its contents may become denser
and drier ; and the bone for a short distance around it may be hard-
ened and solidified ; and all the morbid process may cease. Or, the
surface of an ulcer may gradually heal ; compact hard bone forming
on it, and combining with the thickened and scarred periosteum and
superjacent tissues. Or, lastly, though rarely after tuberculous disease,
when two ulcerated surfaces of bone come into contact, they may unite
and coalesce; as in the anchylosis which may ensue after tuberculous
ulceration of the articular portions of bones, or between vertebrae, in
some of the cases of tuberculous disease of the spine, or among the
bones of the carpus or tarsus. In all these instances, it may be gene-
rally observed that, as inflammation of the bone preceded and bordered
the tuberculous deposits and ulcers, so, when healing ensues, the bone
adjacent to the scar or cavity is hardened, pale yellowish white, less
vascular than in health, and made heavier and more nearly solid by the
thickening of its cancelli.
The instances of tuberculous disease which have now been described
may suffice, I hope, for all that I can have in view ; namely, the illus-
tration of the general characters of the disease and the principal facts
on which to form an opinion concerning its nature and affinities.
On first thought, there may seem little right to assume such a rela-
tion between tubercles and tumors as is implied by their inclusion in
this volume : yet the features of resemblance are not few or inconsi-
derable. The question, broadly stated, is, whether tuberculous diseases
have nearest likeness to inflammations, or to cancers.* It is a very
difficult one to answer, for there are apparently good arguments on
both sides. On the whole, I am disposed to think that the really tuber-
culous diseases are more, and in more significant things, like the can-
cerous than they are like any others. Therefore, I have spoken of
them here, and have arranged the illustrations of them in a correspond-
ing place in the College Museum. But I will now state both sides of
the question.
* The observations of Virchow and Schroeder van der Kolk, respecting the formation of
tuberculous matter in epithelial cells and other natural tissue-elements, are not opposed to
this mode of stating the question. It may be said that there are many points of resem-
blance between tuberculous diseases and the degenerations of parts ; but it would be a very
far, and, I think, a very injudicious, extension of our ideas of degenerations, to include the
process for the formation of tubercles among them. The differences between the tubercu-
lous disease and all the natural processes of merely defective nutrition, separate it widely
from all degenerations properly so called. The tuberculous material naturally degenerates {
but its production cannot be reasonably called a process of degeneration in any normal part'
blgKA8IB.
I. The likcuees between tlie tuberculous diseases and the iftluHM-
lionB with Ijmpb prodacta timt are luast cnpablu of dewlopnciit. aecai
to be shown in these things :
(1.) The likeneBd between tubcrdc and such Ijrinph prodoeU i> «liis
tuo great for diagnosm: they have been, and arc, often oooFcHmdfd;*
and the withered and degenerated nuclei and other particW of wlwk
tubercles are chiefl; cuiupused are, at least, as much like llww vt
degenerate inflammalor; lymph as they are like aoy other mmM
products.
(2.) JnHammation, indicated by all its signs, ia a ootntnoa bat m(
necessary precedent and attendant of tuberculous (leposiL It evidratlf
exists in nearly all casca of the acute, aud in many of the chronic, tuber-
culous affections of thi' glands, lungH, and otiier parts ; and infl'tnmv
tory lymph capable of complete development U eotnetimes mingled mvk
tuberculous matter.
(3.) The degenerations of tuberculous matter are, in all mMolHl
points, parallel with those of inltainmatory lymph ; and so are tke pf*-
ccttees preceding and following the discharge of the liquefied product.
(4.) The same constitutional peculiarities (so far as they can be ob-
served) precede aud attend the tuberculous diseases and tlie so-fsalM
scrofulous inflammations which are not productive of t ubc re alou de-
posits.
Whether, therefore, wc consider the local or the conntitnlional para
of the process, there may seem no boundary-line, no mark indtcatiof
essential dissimilarity between the tuberculous diseases an<l tbc inBa»>
matious producing lymph nearly incapable of development. The cun-
clusion, therefore, might be, that the local disease is a specific influa-
mation, dependent on a peculiar diathesis or conaiitution of th« bluaj,
and to be studied according to its analogies with goat, rlit
syphilis, and the constitutional affections that are mauifested by
inflammations.
On the other side, it may be said — (1) that the likeness Iwt
tubercle and degeiierulcd lymph is only that into whioh k large
of both normal aud morbid products merge in similar degeiteraiioH;
■ The doetrine. now to en
lympb, nnd 'base of tubercle, u
nnd not in an exwlBlinn pourw
m probable eiplnn
cli prMede.nntI, ii
iiily Kninlog ttriiinil. ibal the oorpueSn et H
oul rtoni tbe blooJ {pB«n Wti and 710, niMw>.lH
lion of ibe clOK roemhlnni
^ nnix. Tbm, al
■uge, in all welt-marked caMi tlie rrMmblance belu ten ibe pniceMn eeian,
puKlea BHunie ibrir tpeeiHa channeri. Bui H ii (bould ■> bappvn that <l>a*H
wbiuh miKliI (emi lo fiamp ihem willi >f>eailir rornis lire but (IiEbt. if liia Ijpa'^
I rainlly indicnled, no liiHl tlieir develiipiuent i
cutt, anil ilie iliiiKnniii iin'etHiiily beruniea dllficiili.
■id, of whU'li ii may be liard In say wbelher Ibej ibould bo nvndvd m Wltf
inialory lympti or to tubercle.
AFFINITIES OF TUBERCULOUS DISEASES. 723
(2) that the coincidence of inflammation and tuberculous deposit is ac-
cidental and inconstant, and that the mingling of the developing pro-
ducts of the •one, with the degenerating material of the other, proves
their essential difference ; (3) that the same methods of degeneration,
and of disposal of liquefied materials which are observed in tubercle and
aplastic lymph, may be noticed in other products, — for instance, in
cancerous and other growths with ill-developed structures ; and (4) that
the similarity of the constitutional states only justifies the expression,
that "scrofulous*' persons are peculiarly liable to tuberculous, as well
as to inactive inflammatory, diseases.
II. The chief grounds for regarding tubercle and cancer as diseases
of the same order are the following :
(1.) Tubercles sometimes appear as distinct masses, like tumors, in
the brain, and in other instances of so-called encysted tubercle. And
the dissimilarity between these and tumors, in that they neither grow
by inherent power, nor are vascular, is only because their elementary
structures abort, and very early become degenerate ; it is only the same
dissimilarity as exists between a degenerate, and a growing, mass of
cancer.
(2.) The general characters of malignant tumors, as deduced from
cancers (p. 343), arc also observed in tuberculous diseases : namely, the
elementary tuberculous structures are heterologous ; they are usually
infiltrated, and, at length, exclude, and occupy the place of, the natural
textures ; they have a peculiar tendency to induce ulceration after soft-
ening ; the walls of the ulcer are commonly occupied by tuberculous
deposits like those which preceded it, and, while thus occupied, have no
disposition to heal; the tuberculous deposits apparently multiply in all
the same manners as the cancerous do (compare p. 697, e. s.); and,
whether in their extension or in their multiplication, there is scarcely
an organ or tissue which they may not affect, though, like cancers, the
primary tuberculous diseases have their "seats of election," and differ-
ent seats at different periods of life.
(3.) The tuberculous diathesis, the constitutional state which pre-
cedes the formation of tubercle, is scarcely producible by any external
agencies, except climate ; but it is frequently hereditary : and in both
these respects it resembles the cancerous, and differs from the merely
debilitated state in which the aplastic inflammations occur.
(4.) The cancerous and the tuberculous diathesis appear to be incom-
patible and mutally exclusive : the production of tubercles is extremely
rare, but that of lowly organized inflammatory products is frequent in
cancerous patients. Such incompatibility implies that cancer and tu-
bercle are equally and in the same sense, constitutional diseases ; very
different, yet of the same order in pathology.
(5.) The tuberculous diathesis, like the cancerous, regularly increases,
and is attended with cachexia, which is often disproportionate to the
local disease. It is true that tuberculous disease frequently ceases in
& pnrt, and nllow.i itfi healing ; yet, if we look to its enormoos norlaEt^
as the index of Us natural couree, we must sec in it b Uw of incrm^
like that excmplilied with fewer exceptions in cancers. •And nth a
law is not usually exemplified in the specific inflammatory diseuc*; fir
they generally tend to subside with lapse of time.
If, now, I leave the reader to consider for himself tbe qnotioo thl
may thus be argued, I shall but fulfil a purpose kept in view in til tbi
Lectures, — the purpose, namely, of offering materinls for thoagkl npM
subjects of which I have not knowledge. It will he within theMM*
scope if I suggest a contemplation of the seeming opposition
the chief subjects of the earlier Lectures and the later.
In all the affections considered in the earlier, we may tnwe
and design for the maintenance or recovery of the b(«Iy*» hcftltL.
strengthening against resistance, the reaction after injury, tke '
activity of repair, the collection and removal of infl&mmatory
the easting of sloughs, the discharge of morbid materiala fnm
blood, — all these are examples of the manifold good designs of
and they evince puch strength and width of adaptation to th«
cies of life, that we might think the body was designed n«Ter W Mfr
cumb before the due time of its natural decay.
But in the diseases considered in this Lecture, and in thoM oti tu-
mors, we trace no fulfilment of design for the well-being of tbe Iwdy:
they seem all purposeless or hurtful: and if our thoughts coBeeniiig
purpose were bounded by this life, or were only lightol by ths rayt i
an intellectual hope, we could not discover the signs of beoefioeno
violences against nature, or in early deaths, such u I hmvt ken
scribed. But. in these seeming oppositions, faith can trace the DiviM'
purposes, consistent and continuous, stretching far beyond tbr WisM'
of this life ; and, among the certainties of the future, can s«c folfilM
intention of the discipline of sufferings, that only death might nuii^^allti
And if we cannot always tell what is designed, for themselves, ii
the agony or the calm through which we see men paAS from tbt* worl^
and cannot guess why, for iherr own sakes, some are withdrmwn in th*
very sunrise of their life, and others left to abide till night; jel,
ways, Gon'e purpose, for our own good, may be clearly read in I
warning, that untimely deaths should make us timely wise.
INDEX.
A.
Abernethy, Mr., on olassification of tumors,
351 ; on pancreatic tumors, 485.
Abscess, formation of, 267-270 ; opening of,
282 ; in bone, 279.
Absorption ; preceded by transformation, 60 ;
of bone, 186 ; of degenerate parts, 60 ; of
blood, 137; of bloodyessels, 281 ; of cancer,
701 ; of dead tissues, 320 ; of inflamed parts,
270, 288; of inflammatory lymph, 261, 263.
Actinia, experiments on, 126.
Adenoid sarcomata, 486.
Adhesion, primary, 149 ; secondary, 152.
Adhesions, formation of, 250.
Adhesive inflammation, 149, 235.
Adipocere, 92.
Adipose tissue, increased formation of, 41 :
and see Fat.
tumor : see Fatty tumor.
Affinity, elective, in parts, 62, 93.
Age, as affecting repair, 123 ; general relation
to cancer, 678 : and see Cancer.
Air, cysts containing, 359.
Albuminous sarcoma, 515.
Allocation of cancers, Ac., 577, 784.
Alveolar cancer : see Colloid.
Amputation, healing after, 152, 173.
Amyloid degeneration, 89, note.
Anchylosis, followed by atrophy, 109.
Aneurism ; of bone, 505 ; by anastomosis, 495 ;
effects of pressure by, 79 ; Hunter's opera-
tion for, 46.
Antlers, growth of, after castration, 43.
Antrum, osseous growths of the, 481; polypi
in the, 403 ; teeth in the, 396.
Aplastic lymph, 260, 714, e. s.
Apoplexy, with degenerate cerebral and pul-
monary vessels, 115.
Arachnoid, organization of blood-clots in the,
136.
Arous senilis, 118.
ArrMts of development, 26.
Arterial vascular tumor, 500.
Arteries, contraction of, 196 ; degeneration of,
113 ; healing of injured, 196 ; obstruction of,
inducing mortification, 45, 311 ; inducing
degeneration in cancers, 702 ; ulceration of,
in progress of cancer, 610 ; and see Blood-
▼essels.
Artery, femoral, traversing tumors, 454, 563,
590.
Ascites, fibrine exuded in, 300.
AMimilation, 27 ; of blood, 34 ; in diseased
parts, 27 ; by cancer, 696.
Assimilative force, 64.
AsteridsB, repair in, 124.
Atheromatous affection of arteries, 113.
Atrophy, 81, e. s. ; from pressure, 80 ; modes
of, 84; see Regeneration; of cancerous parts,
091 ; distinguished from inflammation, 298.
Auditory passage, polypi in, 404.
Auricle, cysts fasciculated like an, 368.
Autogenous cysts, 354.
B.
Baly, Dr., on ulceration, 290.
Barky warts, 628.
Barlow, Mr. W. F., on paralysed muscles, 101 ;
on fatty degeneration, 93.
Bats, circulation in the wings of, 213 ; their
temperature, 213 ; rhythmical contraction of
veins, 214.
Baum, Prof., on teeth in the antrum, 396 ; on
aural polypi, 404.
Bell, John, on aneurism by anastomosis, 496.
Bell, Dr. Joseph, on pulsating tumor of orbit,
505 ; on villous cancer, 654, note.
Bell, Sir C, on cancerous cachexia, 553.
Bennett, Dr. J. H., on fibro-nucleated tumors,
517; on cancroid disease, 597; on blood in
inflamed parts, 222.
Billroth, Dr., on development of bloodvessels,
159 ; on cylindroma, 415 ; on mucous polypi,
403 ; on salivary glandular tumors, 416, 456.
Birkett, Mr., on mammary cysts, 382 ; on
mammary glandular tumors, 485.
Bites, Ac., venomous, 331.
Blastema, nucleated, its development, 142 ; see
also Nucleated Blastema.
Bleeding : see Hemorrhage.
Blisters, different fluids in, 237.
Blood, absorption of extravasated, 137 ; accu-
mulation inducing growth, 68 : assimilation
by, 34 ; in cancerous persons, 670 ; initiating
inflammation, 301 ; death of, in dead parts,
318 ; defect and disease of, inducing morti-
fication, 311, 315 ; effusion in inflammation,
232 ; effused, supposed origin of tumors, 348 ;
extravasated, in wounds, its disposal, 134,
137 ; in inflammations, 220 ; influence on in-
flammatory products, 236 ; in vessels of in-
flamed parts, 210 ; life of, 34 ; maintenance
of morbid state of, 57 ; materials of, deter-
mining formation, 40 ; morbid materials in,
36 ; organization of, 135 ; in tied arteries,
200 ; regular supply for nutrition, 45 ; right
state of. for nutrition, 34, e. s. ; clots, soften-
ing of, 259 ; stagnant after injuries, 154;
transference of cancer, Ac., by, 699.
Blood-cells, length, Ac., of life, 32 ; develop-
ment of, 61 ; in inflammation, 221 ; white,
on wounds, 152.
Blood-scabs, 167.
Bloodvessels, absorption of, 281 ; adaptation
to atrophy, 98 ; atrophy of, 112 ; initiating
inflammation, 300 ; of cancers, 564, 694 ; in-
closed by cancers, 563, 590 ; cancerous ulcer-
ation of, 610 ; contraction on stimulus, 214 ;
in granulations, 162 ; enlarged in growing
in«luU*rj
., OD h*«]Iiig of voundi in Iha
Bn^o. lasptu'linn of iknll to, T4, a. >. ; alrn-
pbf of, nil bloodvHMli of, in rxliofUa-
{nK, 2U; IIJ.U in, with Tut, hur. ie., 391;
dtgenarfttioDarininuU ••»•]• of. ll&;*irMU
of iu illasuai aa th« oord. II81 tflMU of
aiereiaa, Ac.. 3S ; pciiotration b} aiMr. S4T ;
■luugbing of, 40; Kiflvniiif of, 1 16 j tubtnia
in the, T33.
Braln-ilkc cpitfatllnl eiin<ian. flOI.
Bniut : oiuiotr nol nHHting glkDiIular tunnrt
Id tbf , IHl . runti of Ch>. raJlovJDg tlia •■'
Bltiun uf KiMxIal" [iimort. 4B] , h«d Ian-
«r of the . u* floirrhogt Cancer : beating
tttw ranmial of, Mt; inilariMoti of. in'
dnancad by Ua mind, 4t> : irritable tDnnr
of ibe. 411 ; maligDBDl Bbroui tnmor in Iha.
6M ; mednllarr aaaaer of, &TT ; oijraloid lu-
nar in Iba, 470 : at* alio Utmmnrj QIand.
Brodia, Sir B. 0., on falljr nulgrowtht, 3SA.
ftnd tonora, 3^8 1 on murtiaeation. SIS. Ac. ,
OD aerpvot-poiaan, 1131 ; on sancaroai tnbat-
Ola, fl3l.
Brood-aalliinaaiHer, 611.
Brow
oy»U
Brown -EaqDard, M., 1
204 : nn Denona 871
Brioh. Dr., caaeofoa
ilJorDanaar-itraud
Bodd. Dr. T
repair at iptnal cord,
>in iu nutriiioD. il.
>er. 670 ^ on maltifom-
'drT" °*'
Casfaaiia in oanear, 704.
Calearaou!! d.pu.it. >ii nhrntiMaini
Oaloarvoni dfgraeratioa. Hi; of I
lis ; of Ijmph, 361. 164; of Mnear. 701
oftnberale. Til, 731.
Catlu : aaa lUpalr ol Fraataraa.
Cucellotu oaiaDai lamoni. 473.
Canocr : ganaral palholog; (tor aneetal paths.
lo^. m tba (peslflo namaa, Boirrboni. Ae.)
Origin of aancar-oelli from pra-eiiatlng tlt-
*aa alamenU, 6av, nolo; hypolbeaii, 668 (
!a dariTad.
tUS : eoneiruelloB, 6M ;
otaanNn in affaeWd parti, Ml
etil-nirina. 681 ; diairnoaia. 69).
itj, 6SI : roofomuV if '
681; itrosia, 6»Sj blsadt
l>try, 6t>4i lllk. 6M; grawU. «■; Na
nondiUaii. «M; l*a«ll« I imt%
aaltipllBstlon. 6VS : by 1
eontlnuana anrTBeaa, AM - 1
diaunt paria, 6W ; bj ine
'^Xt
nfta
inral. 71
.. 713
■ oyiaa. 9M.
CanarmDa growl ha
ertetlle to Bum. & _
man mlinl, 130; folJavlac IW
uannarr Klandalu lumon, WL
pareou . (umora In tba al
4»l.
Canaroid. ART.
CsntiiD. Il
Capillary Taacslat iunu>n
Cawnlaa, laninalad. 613
SOT.
Caralnnma IWIialatitni
Bbroaun, 130. AtO
Oarpanlar. Dr.. oa the ladiii^aal liA af prt|
10, noia ; nn tital and ithyxlnl Gm, d
Cartar, Dr., nn Mvcb in tbr liiwn. *•
Canila«a. repair of. UK , liitiaaiMia 4
IM : inDreaie In IsaaamltM. IM. a^
tion of. 1H«. 193 i in ahr«*alla^ immm
Cartllwlnou tumoral ^eaenl wat«, 136 ■
or In bcaaa, 436 ; aaaatraFtleai. 4J6 ; tailaM.
436; miatOMO|dMla(nicl<ii>, 437. afb^
*m ■ of aalla. 439 . of sDRltf, M* , |
443 ) alia. 443 ; oariftraiiMi. 441 da;
tlon or defart, 4U ; anruniaf, HI
lotid and tiihmailtlwy gUk4a.4J
nalara, 4S7 , r
alunjt lymphall
eoi(iDn<ilinn witl
tunon, 461,
INDEX.
727
Castration, effeots of, on antlers, Ao., 43.
.Catalytic action of discharges, 292.
Caaliflower excrescence of uterus, 619.
CaTcmoas tnmors, 496, 504.
CaTities, tuberculous, 712, 717, 719.
Cellulose, presence probable of, in tissues, 90.
Centres of ossification, hypertrophy at, 74.
Cerebriform cancer : see Medullary Cancer.
Chancre, lymph in, 251.
Channelling of bloodyessels, 162.
Cheesy metamorphosis, 714.
Chemical composition ; relation to vital ac-
tivity, 158.
— ^— changes in granulations, 1 58.
Chimney-sweep's cancer, 629 ; and see Epithe-
lial Cancer.
Cholesterine in cysts, 362, 394.
Cholesteatoma, 393.
Chondroma, 435, note.
Chorion, cystic disease of, 377.
Choroid plexus, cystic disease of, 356.
Chronic mammary tumor, 485.
Cicatrices : see Scars. Cancer of, 623.
Ciliated epithelium in cysts, 355, note.
Clarke Lockbart, Mr., on atrophy of nerve-
cells, 98 ; on connective tissue in spinal
cord, 118.
Climate ; relation to cancer, 680.
Clitoris, cancerous cysts in the,* 389; out-
growth of, 405.
Clivns, exostosis of, 474.
Clot : see Blood-Clot.
Coagulable lymph, 233 : see Lymph.
Cold, producing mortification, 313.
Colloid cancer ; primary seats of, 658 ; general
characters, 658 ; manner and extent of
growth, 659 ; mingled, 660 ; minute struc-
ture, 660; analysis, 661 ; relations to other
cancers, 663 ; general relations of cysts to
cancers, 663 ; general history of, 665 ; like-
ness to cartilaginous tumors, 446.
cysts, 369.
CoUonema, 402, note.
Common disease, 322.
Complemental nutrition, 39, e. s. ; in dis-
ease, 40.
Compound cysts, 373.
Concurrent development of organs, 43.
Conditions of nutrition : see Nutrition.
Condyloma, 628, 685.
Congenital defects ; liability to disease, 643.
'-^——' — excesses ,- contrast with tumors, 341,
note.
hypertrophy, 69.
Congestion, active, 215, e. s. ; mechanical, re-
lation to inflammation, 300.
Conglomerate tumor, 454, note.
Conical clot, 200.
Conjunctiva, inflamed after stimulus of retina,
225, 304.
Connective-tissue corpuscles; their probable
use in nutrition, 48 ; development in new-
formed skin, 205.
Connective tissue ; development of, 144, note ;
mucous form of, 402 ; structure of, 144,
note ; tumor of, 402.
Constitutional disease, 324, e. s. : see Specific
Diseases ; become local, 697 ; in cancer, 669-
704.
Contraction of organised inflammatory pro-
ducts, 252.
Cooke, Dr., case of recurring mammary pro-
liferous cysts, 387.
Cooper, Sir A. P., on chronic mammary tumors,
486 ; on irritable tumors of the breast, 421.
Coote, Mr., on vascular tumors, 501, 507.
Cord, spinal, consequences of injury, 51 ; atro-
phy of, 117.
Cornea, fatty degeneration of, 1 18 ; effects on
inflammation of, 118; ulceration of, 50.
Corns, 79 ; bursa under, 67.
Corps fibreux, 422.
innomin^, 371.
Corpuscular lymph, 234 : see Lymph.
Corrosive properties of discharges, 291.
Cowperian cysts, 366.
Cranium : see Skull.
Croupous lymph, 236, 708, Ac.
Crystals, repair of, 121.
Curling, Mr., on atrophy of bone, 97; on flbro-
cystic disease of the testicle, 427; on scrotal
cancer, 600, 635.
Cutaneous outgrowths, 405.
proliferous cysts, 889 ; with perfect
skin, 390 ; in the ovaries, 390 ; in the sub-
cutaneous tissue, 390; in various parts, 391.
Cuticle, life of, 31; thickening of, 79; devel-
opment of new, 205 ; formed on granulations,
156 ; separating over abscess, 284.
Cuticular cysts, 391.
Cylindroma, 415, note.
Cysts or cystic tumors, 358 ; primary and se-
condary, 354 ; mode of origin, 354 ; general
structure of, 355 ; modes of development,
355 ; their various contents, 357 ; endoge-
nous formation of, 375 ; with endogenous
cancerous growths, 389; exogenous forma-
tion of, 376 ; with cholesterine, 362 ; colloid,
369 ; complex ovarian, 375 ; compound or
proliferous, 373 ; connected with Cowper's
glands, 366 ; with organ of Girald^, 371 ;
with organ of Rosenmiiller, 374 ; cutaneous
proliferous, 389 ; gaseous, 359 ; glandular
proliferous, 379 ; mammary proliferous, 380 ;
Meibomian, 300 ; mucous, 366 ; containing
oily or fatty matter, 369 ; proliferous in the
thigh and other parts, 384, 385 ; proliferous
recurring, 386 ; sanguineous, 367 ; sebaceous,
epidermal, or cuticular, 391 ; containing
semen or other secreted fluids, 370 ; serous,
359 ; simple or barren, enumeration of, 353 ;
synovial, 365 ; containing teeth, 395 ; with
cancer in the breast, 364 ; with cancers of
glands, 580; with epithelial cancers, 613;
general relation to cancers, 663 ; in cartila-
ginous tumors, 446 , in fatty tumors, 401 ;
in fibrous tumors, 426 ; in myeloid tumors,
463; in vascular tnmors or nesvi, 361, 507.
Cystic Cancer : see Colloid.
Cystoid growths, 373.
Cysto-carcinoma, 389, note.
sarcoma, 373, 389, 488.
Dalyell, Sir J. G., experiments on Hydra Tu-
bularia, Ac, 126, e. s.
Dead parts, separation of, 59.
Death, and degeneration, distinguished, 59,
309 ; natural, of parts, 27.
Decay, natural, of parts, 27 : see Degeneration,
81.
Degeneration ; general meaning of, 82 ; natural
occurrence in old age, 82 ; natural issue of
life, 82 ; design of degenerations, 83 ; their
importance in pathology, 83 ; methods of, 84 ;
amyloid, 89, note ; withering, 84 ; fatty, 84 ;
calcareous, 84 ; pigmental, 85 ; thickening of
primary membranes, 86 ; combinations, 86 ;
728
INDEX.
their ocourrenee before old age, 86 ; distine-
tioD from diaeaees, if6 ; general diagnosis,
87 ; relations witli development, 88 ; and
with diseases, 88 ; liqaefactive, 89 ; condi-
tions of, 96 ; spontaneous atrophy or degene-
ration, 98 ; contrast, with hypertrophy, 96.
and death distinguished, 59, 309 ;
mixed with morbid processes, 33 ; of the
fangs of teeth, 31 ; in inflamed parts, 276-
288; of lymph, 258, 274, 714; of cancer-
cells, 527,588, 611,643; of tubercle, 711;
of cancers, 701.
Dendritic vegetation. 575, 655.
Dentigerous cysts, 395.
Deterioration of parts, sources of, 27.
Determination of blood, 215, e. s.
Development, meaning of, 26, 246 ; separate
from growth, 26 ; arrests of, 26 ; determina-
tion of the order of, 41 ; as part of the for-
mative process, 60 ; in hypertrophy, 67 ;
consumption of force in, 122 ; checked se-
parately from growth, 123; arrest or error
of, in granulations, 157; congenital excess
of, contrast with tumors, 341, note.
Diseased parts, assimilation in, 56.
Diseases occurring only once, 56
Diseases of cancers^ 702; of granulations, 157;
of organized lymph, 274.
Dittrich, Prof., on pulmonary apoplexy, 116.
Dropsies, mechanical, 232; fibrinous, 230, 240,
Ac.
Duration of life in parts, 31.
Dysentery, ulcers in, 290.
E.
Ear, vascular tumor of the, 500 ; fibrous tu-
mors in the lobules of the, 434.
Eburnation of bone, 280.
EcchondroBis prolifera, 474, note.
Ektasie, cavernous, 503, note.
Elastic tij>8ue in adhesions, 252; in fibrous tu-
mors, 42»>.
Election, seats of, 37.
Elective affinity in nutrition, 61-63.
Elephantiasis scroti, 405.
Encephaloid : see Medullary Cancer.
Enchundroma, 435, e. s. : see Cartilaginous
Tumor.
Endogenous cells, in cancer, 612.
cysts, 375 : see Cysts*.
Epidermal cysts, 391-395.
Epidermis, growth of, 65.
Epithelial cancer; primary seats, 596 ; second-
ary, 596 ; superficial form,, 598; warty and
other external characters, 598 ; distinction
from common warty growths, 601, 630 ; in-
terior structure, 602; peculiar soft material,
602 ; papillary and deep-set portions, 603 ;
infiltrated cancer-structures, 604 ; stroma,
605 ; deep-se^ited form, 605 ; cases, 606 ; ul-
ceration, 608; microscopic structures, 610;
their arrangement, 610 ; varieties, 612 ; me-
lanotic. 615 ; cylindriform, 615 ; intermedi-
ate, 016. In lympfuitic glrifids, 616; pri-
mary, 017; lungSj 618; hearty 619; uterus
and vagina, 019 ; diagnosis from other can-
cers and from rodent ulcers, 621 ; cancer of
cicatrices, 623. Pathology : influence of sex,
624; age, 625; hereditary disposition, 626;
injury or disease, 627 : warts, 628 ; cancer ;
structures new formed in them, 629 ; general
health, 631; growth, 631: ulceration, 631 ;
pain and cachexia, 632 ; multiplication, 632 ;
variations aeeordtag to seal, 634 ; dnratiofi
of life, 034; rales for opermtioiM, 635; in
cases of reenrreiiee, 636 ; ralations to oiber
cancers, 637.
EpitheliomJ^ 597.
Epithelium, on adhesions, Ae., 252.
Epulis, 433, 466.
Erectile tumors, 495, 575.
Erysipelas, suppuration in, 270.
Ethmoid bone, with cartilaginoas growth, 451.
Excoriation in inflammation, 289.
Excretion oflSce of each part, 39.
Excretions, mutual, between organs, 44/
Exercise, effects of, in tissues, 27; inducing
growth, 68 ; atrophy in defeetire, 96.
Exogenous cysts, 376.
Exostosis, 473 ; foliated or periosteal, 646 ;
spongy or fungous, 567.
Exudations, inflammatory, 229, 233.
Eye, acute cancer of the, 584 ; modnllary can-
cer of, 585, 587, 588 ; melanoid cancer of,
641.
Eyelash, life of an, 30.
Face, growths on the bones of the, 480.
Facial nerve, influence on nutrition, 53.
False membranes, 250, 256, Ac.
Fat, formed in adhesions, 252 ; in the place of
atrophied muscles, 100.
Fatty degeneration, 90 ; general characters of^
91 ; wasting of nuclei, 91 ; source of the Catty
matter, 91 ; imitative chemical changes, 93 ;
adipocere, 92 ; relation to defective nntfi-
tion, 93; as in old age, 93; two modes of
atrophy in old persons, 93 ; causes of fatty
degeneration, 94 ; correspondence with those
of wasting, 95 ; relation to general obesity,
95 ; voluntary muscles, 99 ; of the heart,
103 ; of the uterus and the smooth-fibred
muscles, 107 ; of bones, 108 ; of bloodvessels,
112; nervous tissues, 116; cornea, 118;
lymph, 260, 263, 273 ; of inflamed parU, 285 ;
of transplanted parts, 260.
matter, in degenerate parts, 60 ; in the
uterus after delivery, 108.
tumors : outgrowths, 396 ; in the heart,
396 ; tumors, tissue of, 397 ; its arrange-
ment, 397 ; capsule, 398; bloodvessels, 398;
multiplicity, 398 ; seats, 398 ; shifting, 399 :
deep-seated, 400 ; growth, 400 ; diseases,
401 ; causes, 402; in emaciated persons, 340.
Femur, lengthening of, 76 ; absorption of neek,
281; tumor detached from the, 475; fre-
quent seat of osteoid cancer, 646.
Fever, cancer withering in, 674.
Fibrine in lymph, 139; in efi'used fluids, 230 ;
delayed coagulation, 231 ; varieties of, in
inflammatory exudations, 237 ; degenera-
tions of, 259.
Fibrinous lymph, 233.
Fibro-calcareous tumors, 427.
cellular tissue, development of, 140, e. !u
and fibrous tissues, formed from
lymph, 139, 250.
tumors. Previous descriptions.
402 ; Polypi : of the nose, 403 ; antrum,
403 ; ear, 404; urinary bladder, 404; rec-
tum, 404 ; vagina, 405 ; lacrymal sac. 405.
Cutaneous outgrowths: elephantiasis, 406;
Fibro-cellular tumors, general form, Ac., 406;
texture, 407 ; microscopic structure, 407 ;
chemical character, 40 7 ; containing cartilage
INDEX.
729
or bone, 408 ; degenerate, 408 ; seats, 409 j
in the sorotam, 409 ; by the Tagina, 410 ;
in the limbs, 413 ; in the testicle, Ao., 413 ;
general history, growth, Ac., 414.
FibroKsystie tnmors, 426 ; with cartilage, 401 .
Fibroid tamors, reearring, 509, e. s.
Fibro>naeleated tamors : general characters
and cases, 517.
plastic tamors, 462.
Fibrous cancer. 665.
tissue, developed from lymph, 250 ; os-
sification of, in bony tamors, 479 ; fibroas
tnmors in or near, 431 ; in cancer, 524-530.
tamors. Polypi : of the oteros, 422 ;
of the pharynx, 422. Tnmors, general shape,
423 ; capsule, 423 ; texture, 423 ; plan of
fibres, 424 ; vascularity, 424 ; microscopic
structure, 425 ; muftcular and other mixed
tissues, 425 ; cysts, 426 ; calcareous deposits,
427 i fatty degeneration of, 429. note ; soft-
Generalization of tamors, 459.
Genital organs, relations of development of, 42.
Gerlach, Dr., on osteoid cancer, 649 ; on vil-
lous cancer, 656.
Giraldes, organ of, 371.
Glands, products of inflamed, 241.
Gland-cells, length of life, 33.
duct«, involved in cancer, 524.
growths, intra-cystic, 341, 379, e. s. ,*
outlying, 342.
Glandular tumors : general relations, 484 ;
mammary, 485 ; usual seats, 486 ; shape,
Ac., 486 ; construction, 487 ; structure, 487 ;
microscopic structure, 488 ; growth, 489 ;
pain, 489 ; disappearance, 490 ; large sise,
490 ; in the male, 490 ; relation to cancer,
491-2 ; in cancerous families, 492. Labial,
492. Prostatic, 494. Thyroid, 494. Mixed,
on the parotid and submaxillary glands, 454.
Globes, ^pidermiqnes, 613.
Glnge, Prof., on albuminous sarcoma, 515; in-
flammatory globules of, 263.
ening, 429 ; seats, 429. Subcutaneous, 430 ;
protruding, 431 ; near fibrous tinues, 431 ;
of the jaws, 432 ; in the lobules of the ears, | Goodsir, Mr., on absorption and ulceration, p.
434 ; multiplicity, 434 ; growth, 435 ; gene-
ral nature, 435 ; malignant, 665 ; of the
breast, 485.
Fibula, acute cancer of the, 584 ; cartilaginous
tumor in the, 449.
First intention, union by, 145, 149.
Fbrster, Prof., on aural and other polypi, 404,
note ; on myoma, 426, note ; on salivary
glandular tumors, 456, note.
Food, effects of, in the formation of tissues, 41.
Foot, atrophy of, 81 ,* cartilaginous tumor, 451 ;
fibro-cellular tumor in the, 413 ; fibrous tu-
mor in the, 431.
Forces, actuating the formative process, 62.
Form, organic, dependent on composition, 63.
Formative force, 62 ; its method, 63 ; hypo-
thesis concerning, 63 ; illustrated in repair,
121 ; consumed in organising, 122.
process ; its modes, 26 ; its precision,
36-63 ; disposal of old particles, 59 ,■ degene-
ration and death, 59 ; instanced in teeth, Ac.,
59 : development of new particles, 60 ; in-
fluence of nuclei, 61 ; repetition of parts, 61 ;
likeness to older structures, 61 ; nature of
formative forces, 61 ; theory of assimilation,
62 ; its inapplicability, 62 ; formative or
plastic force, 62 ; as in development, 63 ; its
method, 63 ; dependence of form on compo-
sition, 64; hypothesis, 63; see, also. Nutri-
tion.
Fractures, share of the blood in repairing, 136 ;
followed by partial atrophy. 97 ; ununited,
187 ; spontaneous, in atrophy, 109 ; in mol-
lities ossium, 110 ; in cancerous patients, 538;
see Repair of Fractures.
Frogley, Mr., cases of cartilaginous tumors,
443.
Frog's web, experimental injuries of, 153, 213,
Ac.
Frontal sinuses, osseous tamors in the, 476.
Fongus hssmatodes, 645.
G.
Ganglions, 365.
Gangrene : see Mortification ; relation to ul-
ceration, 290.
€Kweous cysts, 359.
Gelatiniform cancer : see Colloid.
Gelatinous polypi, 403.
•— ^— -— sarcoma, 402, 454, note.
291, note; on endogenous development of
nuclei in cysts, 357, note ; on formation of
new bone, 180, note ; on ulceration of carti-
lage, 286.
Graafian vesicles forming cysts, 353.
Granulations, process of, 152 ; and see Repair
by granulation ; ossification of, 177; effects
of inflammation and congestion on, 248 ; of
cancer, 548.
Granulation cells, 140; on bones, 142.
Granule-cells and masses, 263, Ac.
Growth, meaning of, 26 ; separate from devel-
opment, 26, 123 ; its nature, 64 ; various du-
ration, 64 ; adapted to need, 65 ; hypertro-
phy, 65 ; its rule, 65 ; instanced in cuticle
and muscle. 66 ; with development, 66 ; in
the uterus, Ac, 66 ; conditions necessary, 67 ;
conditions inducing hypertrophy, 68; in-
creased exercise, 68 ; increased materials for
nutrition, 68 ; increased blood, 68 ; morbid
and inflammatory hypertrophies, 69 ; con-
sumption of force in, 123 ; see, also, Hyper-
trophy.
Gulliver, Mr., on degeneration of arteries, 113 ;
on softening of clots, 260.
Gum-cancer : see Colloid.
Gums, cysts connected with the, 362 ; fibrous
tumors of, 433.
Hssmatoid Cancer, 645.
Hair, life and death of, 30 ; change of color
under nervous influence, 53 ; excretion by,
40 ; increased growth in afflux of blood, 68 ;
in cysts, 391 , a. s.
Hair-follicles ; growth into cysts, 392.
Hall, Dr. C. R., on formation of tubercle, 710,
note.
Hancock. Mr., on fatty degeneration of the
bladder, 107.
Hands, cartilaginous tumors in the, 451.
Hannover, Prof., on epithelioma, 597, 616,
Ac.
Harelip ; healing after operations, 152.
Harting, Prof., on growth of muscles, 72.
Hawkins, Mr., on cancerous ulcers, Ac., 621 ^
623 ; on epulis, 433 ; on cystic tumors, 507.
Healing : see Repair ; in paralysed limbs, 52 ;
of ulcers, 293.
Heart, atrophy and degeneration of, 90, 97, e»
47
780
INDKX.
K. 103; oaneer in, 619, 679 ; Utiy degenera-
tion of inlUmed, 103, 286; fatty growths
in, 806 ; growth of, 64; malformed. 26.
Helmbolti, Prof., on changes in mnsoles, 28.
Hemiplegia, state of mosclee in, 101.
Hemorrhage, arrest of, 197 ; from canoers, 589 ;
from fibrous tamors, 65.
Henle, Prof., theory of inflammation, 305.
Hereditary transmission of properties, 675;
disposition to cancer, 674 ; disease, trans-
formation in, 327; cartilaginous tumors,
459 ; cysts, 391 ; osseous tumors, 482.
Hernia, lymph in the sac and intestine, 240 ;
with sloughing, 318.
Herpes, lymph of, 234, 265.
Hewett, Mr. Prescott, on membranes formed
from blood-clots, 135.
Hodgkin, Dr., his account of cysts, 374.
Home, Sir E., on Tessels in lymph, 257.
Homologous parts, similar diseases of, 38.
Homologous and heterologous tumors, 343.
Horns, epithelial cancers like, 600.
Humerus, cartilaginous tumors on the, 448 ;
> osteoid cancer of, 653.
Humphry, Dr., on hypertrophy of muscles, 71 ;
on softening of fibrous tumors, 428 ; on re-
moval of tumors, 394.
Hunter, John, on effects of pressure, 79; on
hypertrophy of muscles, 70, 72 ; on incom-
patible diseases, 674 ; on increased action in
inflammation, 295 ; on mollities ossium, 110 ;
operation for aneurism, 46 ; on subcutaneous
iqjnriM, 132; on union by flrst intention,
' 145 ; on union of granulations, 165 ; remoyal
of large tumor, 455.
Huxley, Mr., case by, 335.
Hyaline cylinders, 415, note.
Hydatid mole, 375.
Hydra, repair in, 124.
Hydrocele-floid, 230 ; encysted, of the cord,
370 ; with spermatosoa, 372.
UydrocepbaloB, hypertrophy of ^kull in, 73.
Hydrops fibrinosus, 230.
Hygromata, 359.
llyperostoses, 473.
Hypertrophy : for general history, see Growth.
Of urinary bladder, 70 ; other involuntary
muscular parts, 71 ; induced by obstacles to
their action, 71; growth of fibres, 72. Of
bone : in the skull, 73 ; in hydrocephalus,
73 ; with shrinking of the brain, 74 ; es- =
pecially at the original centres of ossification,
74. Lengthening of bones, 76 ; with curva-
ture of the tibia, 77 ; inequality of limbs, i
78. Of cuticle, 79; efi'ects of pressure, 79; ,
from within and from without, 80 ; occasional [
jind constant, 80. Of thyroid and other '
glands, 341 ; of mammary gland, 486; of
cancerous parts, 69 1 ; contrasted with tumors, '
•337 ; distinguished from inflammation, 298 :
inflammatory, 241 ; discontinuous and con-
tinuous, 350.
I.
Ichor, 292.
Imbibition, by parts in nutrition, 47.
Immediate union, healing by, 134, 146.
Impairment of parts, sources of, 27.
Inaction, or incubation, after injury, 153,
327.
Incompatibility of cancer and other diseases,
674, 723.
Incorporation of materials of the blood, 40,
329.
Inomsted wartf , 629.
Incubation of disease, 328, 88S, Ae.
Infiltrations, general eharaetam of. 343, 350.
Infiammation, phenomena of: traiititloM to It
from normal nntriUon, 209 ; altorod supply
of blood, 209 ; enlargement of veflMls, 219;
method of, 210 ; go^ng with blood, 221 ;
increased redness, 211 ; appeanuMO <tf new
▼essels, 212 ; changed ^ape of ▼•aseU, 212;
changed movement of the blood, 213 ; ob-
servfS in bats' wings, 213; oontraotion of
stimulated yesselt, 214 ; subsequent dilata-
tion, 214 ; adapted movement of the blood,
215; effects of various stimuli, 215; pro-
ducing determination of blood, 215 ; retar-
dation of blood, 216 ; stagnation, 218 ; ob-
servations in bats' wings, 218 ; summary cf
changes in the blood and vessels, 218 ; non-
coagulation of the stagnant blood, 219;
cansea of the changed movement of the
blood, 220. Changed composition of the
blood, 220; change in its corpuscles, 221.
Ohanged nervous force, 224 ; ** excitement,"
224; transferred disturbance of the force,
225 ; eases of this, 225. Changed state of
the infiamed part, 225. Aecovery, 228.
Products of inlUmmation : Sai mm, 230 ; con-
taining fibrine, 230; delayed coagulation,
231 ; distinction from fluid of meehanisal
dropsies, 232. Blood, 232 f frequency in
pneumonia, 232 ; blood-stained lymph, 232.
Lymphs 233; fibrinous, 233 ; oorposeular,
234 ; lymph-corpuscles, 234 ; their develop-
ments, Ac., 235 ; mixed lym]^, 235 ; relations
to organisation, 235 ; plastio and aplastic
varieUet, 235; relations to adhesive and
suppurative inflammation, 235. Influence
of the blood on inflammatory lymph, 236;
observed in the effects of blisters, 237. In-
fluence of the tissue inflamed, 239 ; ex-
amples and exceptions, 239. Influence of
the degree of inflammation, 240, 244 ,- mixed
lymph and normal blastema, 240, 249. Sum-
mary of influences det«rmining adhesive or
suppurative inflammation, 242. Mttrut,
242 ; mixed lymph, 243 ; pigmental cells,
244. Developments of lymph, 245; its inde-
pendent life, 245 ; and meaning, 246 : and
necessary conditions, 247 ; cessation of in-
flammatory procfw, 247 ; and of passive con-
gestion, 248 ; what determines the direction,
248; formation of adhesions, Ac., 248: of
fibrous or connective tissue, 248 ; its con-
traction. 252; of adipose tissue, 252; of
elastic tissue, 252; epithelium, 252; bone,
252 ; cartilage, 254 ; blood %'e«isels, 256 .:
lymphatics, 266 ; nerre-flbreii. 256 ; times
for development, 256. Degenerations of
lymph, 258 ; conditions favoring. 259 ; in
Jibrinfy withering, 259 ; fatty, 26y ; liqnefae-
tive, 26] ; resolution, 261 ; calcareous, 261;
pigmental, 262 ; in thf co-pu*rles^ withering,
262 ; fatty, 263 ; absorption of granular mat-
ter, 264 ; calcareous, 264 ; pigmental, 264.
Pus : inflammatory suppuration ; origin of.
from pre-existing tissue elements, 266. note:
transformation of lymph into pus, 264 : re-
lations of inflammatory and reimrative sap-
puratioo, 266; abseesSy 267; its formatioo,
Ac.. 268; opening, 283; chronic abscesn.
270 ; diffuse suppuratioM, 270 ; svper^eial
suppuration^ 271 : relation of pus to mucas,
272 ; relation to abrasion and ulceration,
272 ; degenerations of pus-cells, 273 ; variooi
contents of ohronie and recurrent abseessei.
INDEX.
781
273. Degenerations of organized lymph^
274 ; wasting, 274 ; fatty and oaloareoas,
274 ; pigmental, 274 ; diseases, 275 ; hemor-
rhages, inflammations, fto., 275. Changes in
the tissues, inflamed : all injorioas, 276 ;
their doable source, 276 ; softening, 276 ,*
expansion, 278; absorption, 279 ; in opening
of abscesses, 283 ; fatty and other degenera-
tions, 284 ; calcareous, 287 ; penetration of
elements, 288. Ulceration, 288; dependent
on inflammation, 289 ; ejection of particles,
289; solution of them, 291 ; corrosion, 291 ;
ichor, 292 ; healing, 293. Nature and causes
of inflammation : necessary constituents,
293; quantity of nutrition in inflammation,
295 ;" increased action," 295; diminished
formative force, 295 ; method of nutrition
in inflamed parts, 298. Causes^ 299 ; in
changes of bloodvessels, 300 ; in the blood,
301 ; its localization, 302 ; in disturbed ner-
Tous force, 304 ; in the stat« of parts, 305.
Inflammation leading to mortification, 310,
312 ; specific, 322, e. s. ; relation to repair,
207 ; interfering with union, 149 ; in cancers,
702 ; with tubercle, 722, Ac.
Inflammatory hypertrophy, 69.
-^-^— • products; contrasted with tumors,
338.
Iigury, inaction after, 153 ; engendering in-
flammation, 307 ; killing parts, 310 ; making
apt for constitutional disease, 303, 333 ; as
cause of tumors, 348, 686.
Innocent and malignant tumors, contrast be-
tween, 343 ; fusion of, 706.
tumors, general characters of, 347 ;
occasional constitutional origin of, 348 ; be-
coming cancerous, 580, 684 ; in members of
cancerous families, 626 ; cancerous disposi-
tion fading in, 676.
Inoculable diseases, 40, 302, 329.
Inoculation of cancer, 677.
Insects, repair in, 128.
Integuments, cancer of : see Epithelial Cancer;
tubercle in the, 717.
Intermuscular tissue, fibro-cellnlar tumors in
the, 412 ; cancer in, 537, 563.
Intestines, with gaseous cysts, 359.
Intestinal canal, hypertrophy of, 71 ; hard
cancer of, 538 ; medullary cancer of, 58 1-.
Intra-oystic glandular growths, 379, e. s.
Irritation, 209.
Ivory-like osseous tumors, 476.
J.
Jaw, atrophy with anchylosis, 109 ; cartilagi-
nous tumors on the, 450 ; cysts in front of
the, 362 ; dentigerous cysts in the, 395 ;
fibrous tumors on or in the, 432 ; ivory-like
tumor of the, 478, 480 ; myeloid tumors on
or in the, 466 ; osseous tumors of the, in ani-
mals, 479.
Jenner, Dr., on degeneration, 113; on calcare-
ous molecules in colloid cancer, 661.
Joints, cartilaginous growths in, 436 ; effects of
inflammation about, 251 ; effects of chronic
inflammation, 254 ; false, 188 ; loose bodies
in, 436 ; loose bone in, 80 ; softening of liga-
ments, 279.
Jones, Dr. Bence, on changes of materials of
the brain, 28, 297.
— ^--^— Wharton, Mr., on the circulation in
the bat's wing, 214 ; on the blood in inflam-
mation, 222 ; experiments on inflammation,
216, e. s.
Juice of cancer, 525, 564, 573.
K.
Keloid, 406.
Kidney, inflammation in, 287; cystic disease
of, 356 ; effect of destruction of one, 40.
Kirkes, Dr., on adhesions of the pericardium,
261 ; on obstruction of cerebral arteries, 1 16.
KSlliker, Prof., on dilated small bloodvessels,
212; on the change of hairs, 31 ; on degene-
ration in the uterus, 107.
Kreatine, in transformed muscles, 60.
L.
Labial glandular tumors. 492.
Labium, fatty tumor in the, 399 ; fibro-eellular
tumors in the, 41 1 ; outgrowths of, 405 ; pro-
liferous cysts in the, 384.
Lactiferous ducts, dilated into cysts, 363 ; in-
volved in cancer, 528.
Laminated, capsules, 613; cells in myeloid
tumors, 469 ; in epithelial cancers, 613 ; epi-
dermal scales in cholesteatoma, 393.
Lanugo, purpose of, 39.
Lardaceous tumor, 398.
Larynx, cysts in front of the, 361 ; epithelial
cancer of, 696.
Latency of disease, 327-334 ; of cancer, 676.
Lawrence, Mr., on determination of blood.
219 ; on fibro-cellular tumors, 402 ; on glan-
dular tumors, 485, e. s.
Lebert, M., on inflammation, 210, 212, Ac. ; on
lipoma, 396; on mammary glandular tumors,
486 ; on fibro-plastic tumors, 461 ; on vesfiels
of cancers, 564 ; on cancer and oancroid, 597,
625. 661, Ac.
Lepoides, 628.
Liebig, Dr. G., on transformation in muscles,
28.
Life of blood, 32.
individual, of parts, 28 ; length of, in each
part, 31 ; independent in morbid products,
245.
Ligaments, softening of inflamed, 278.
Ligature of arteries, effects of, 198,
Limbs, unequal length of, 76, e. s.
Line of demarcation, 319.
Lions' bones, symmetrically diseased, 36.
Lip, arterial tumor on the, 501 ; cancer of, 628 :
and see Epithelial Cancer; glandular tu-
mors in the, 492 ; glandular and bony tumor
in the, 460 ; proliferous cysts in the, 384.
Lipoma, 396 : see Fatty Tumor ; arborescens,
398, 655 ; colloides, 401 ; mixtum, 398.
Liquefaction of fibrine, Ac., 261.
Liquefactive degeneration, 89 ; in cartilaginou.o
tumors, 445 ; in cancer, 703 ; in tubercle,
711.
Lister, Prof., influence of nerves in nutrition,
52 ; on exostosis, 474 ; on inflammation, 219,
e. s. ; on structure of veins and arteries, 214.
Listen, Mr., on spermatozoa in cysts, 370.
Liver, cancer of the, 688.
Lloyd, Mr., on spermatozoa in cysts, 370.
Local disease in cancer, 670.
Lung, cartilaginous tumors in, 436, 458 ; can-
cer in, 699; epithelial cancer of, 618; os-
teoid cancer of, 653 ; tubercle in the, 707.
782
INDBX.
Ljrmph, for repair, 139 ; in primary adhedon,
140; inflammatory, 233; ite developmenta,
139 ; into flbrona or oonneetiTO tiMae, 157 :
see Inflammation ; degeneration of, 258, 274 ;
Tarieties of, in blifltera, 237 ; supposed origin
of tumors, 348.
Lymphatio glands, olironic inflammation, 202 ;
tubercle in, 710 ; enlargement before eanoer,
533; epithelial oanoer of, 010; medullary
eanoer of, 580 ; osteoid eanoer of, 048 ; seir-
rhons cancer of, 533.
Lymphatics, in adhesions, 257 ; ? in granula-
tions, 104 ; cancer in, 097 ; in cancer, 505 ;
extension of cartilaginous growths in, 458.
Lymph-space in bloodressels, 211.
M.
Macartney, Dr., on immediate union, 140;
modelling process, 108.
Maclagan, Dr., case of recurring flbroid tumor,
510.
Maintenance, 27 ; of diseased blood, 57.
Malignant and innocent tumors, fusion of, 700.
tumors : general characters of, 343 ;
flbrous tumors, 005 ; myeloid tumors, 471.
Malum senile, 109.
Mammary gland : contracted and indurated,
with cysts, 304 ; serous cysts in the, 303.
Mammary glandular tumors, 380, 485 ; neu-
ralgic, 421 ; proliferous cysts, 380 ; recurring,
380.
Many-nucleated corpuscles in myeloid tumors,
404.
Maxillary bones : see Jaws.
Median nerve, consequences of injury of, 50.
Mediastinum, tumor in, containing teeth, Ac.,
395, note.
Medicines, incorporated in tissues, 41, 829.
Medullary cancer : yarieties, 501 ; general re-
lations, 562; usual seats, 562; $oft kind;
shape, Ac., 563 : relation and attachments of
lobes, 563 ; capsule, 563 ; material, 563 ;
cancer juice, 563 ; varieties, 564 ; bloodves-
sels, 564 ; erectile and pulsating, 565 ; lym-
phatics, 565 ; nerves, 566 ; injiltiatiotis^ 560 ;
in bones, 567 ; with osteoid cancer, 567 ; firm
kiiul^ 567. Microscopic characters, 569 ;
cells, 569 ; varieties of nuclei, 569 ; of cells,
571 ; of stroma, or intercellular substance,
573 : affinity with erectile tumors, 575. In
the testieUf 576 ; eye. 577 ; breast, 577 ; snh-
cutawous tissue, 579; multiplicity, 579;
absorption, 580 ; lymptiatic glands, 580 ;
rectum, 581. Pathology: influence of sex,
582 ; age, 582 ; hereditary disposition, 583 ;
injury and disease, 584; temperament, 585 ;
multiplioity and growth, 585 ; arrest, 586 ;
ulceration, 586 ; degenerations, 588 ; wasting
and absorption, 588 ; bleeding, 589 ; inflam-
mation. 589 ; sloughing, 590 ; pain, 592 ;
cachexia, 592 ; duration of life, 593 ; effect
of removal, 593 ; recurrence, 594 ; rules for
operations, 595.
Melanoid cancer; general characters, 639
microscopic, 639; general pathology, 641
color, 643 ; connection with moles, 643
multiplicity, 644.
Meliceris, 362, note.
Membranes, products of inflamed, 241, 243,
250.
Memory, connection with nutrition, 58.
Menstruation, relation to cancer, 543.
Meryon, Dr., on atrophy of muscles, 98, note.
Metamorphosis, in disease, S27.
Mettenheimer, Dr., on the oyatle ehorloa, S78.
Milk : cysts oontaiDing, 303.
Miller, Prof., on painful mboniaiiMMis imaor,
417 ; on eartilaginons inmors on baads, 453.
Mind, effeets of its exeroisa, 28; its InflMBOs
on nutrition, 49 ; oonneotton with a changing
brain, 58 ; depression of, in relation to ean-
oer, 080.
Mixed tumors : flbro-oellnlar and eartiiagiaoas,
407 ; cartilaginous and myeloid, 401 ; eartlla-
ginous and flbro-cystie, 400 ; oartUaginois
and glandular, 454 ; eartilaginons and eaa-
cerons, 459.
Modelling prooess, 108.
-^— of united
united bonet, 186.
Moles : liability to eanoer, 043.
Mollities ossinm. 109 ; its two forms, 112, 280 ;
reference to additional eases : see Addenda.
Molluscum simplex, 405, note.
Morbid materials in blood, identity of, 37 : sse
Speoiflc Diseases. *
Morbid poisons, 825, e. s. : see Speeifie Dissasss.
— — - stmetnres, maintananoe in, 66.
Morgagni, hydatids of, 371.
Mortification: distinetion flrom degeneratioa,
309; oauses, 310; direet, 310; relation to
inflammation, 310 ; indireei, 31 1 ; senile
gangrene, 812; rariona eansee, 312; ap-
pearanoes of dying and dead parts, 315;
separation of them, 319 ; phenomena of ne-
crosis in bone, 320 ; after losi of blood, 46;
after obliteration of Teasels, 46 ; after iijluy
of the spine, 50.
Motor nerves, inflnenee on nntritioB, 63.
Mueous cancroids, 416, note.
^— — oysts, 300 ; Nabothian, 866 ; Cow-
perian, 366 ; their varions contents, 366.
membranes, oanoer of : sae Bpithelial
Oancer ; villous caneer in, 664.
polypi, 402, 403.
tissue, 402, 416, 450.
Mucus, 242 ; diagnosis from pus, 272.
MUller, Prof., on cholesteatoma, 393 ; on en-
chondroma, 435 ; on carcinoma reticulare,
528 ; on osteoid cancer, 040 ; on cysto-sar-
coma, 373, 389, 488, Ac.
Multilocular cysts, 373.
Multiple tumors, 347; cartilaginous tumors,
459 ; fatty tumors, 398 ; flbrous tumors, 434 ;
osseous growths, 483.
Multiplication of cancers : see Oancer, general
pathology.
Muscles, growth of, 00; hypertrophy of, 70,
e. s. ; effects of action, 28 ; atrophy and de-
generation of, 99 ; voluntary, 99 : the heart,
102 ; smooth-fibred, 107 ; materials derived
from their transformations, 00 ; healing of
divided, 195 ; infiammation of, 285 ; hard
cancer in, 536.
Muscular tissue in fibrous tumors of the utenu,
425.
Myeloid tumors : relation to the fibro-plastie,
461 ; affinity to natural bone-textures, 462;
situations, 402 ; general shape, 403 ; texture,
463 ; cysts, 463 ; microscopic structure, 464 ;
general history, 405 ; cases, 460 ; recurrence
and multiplicity, 470; with cartilage, 461.
Myoma, 426.
MyxomaU, 402.
N.
Nabothian cysts, 300.
NsBvi, 497, 505 ; pigmentary, liable to cancer,
043.
INDEX.
733
Neok, serous eysts in the, 360 ,* blood-cysts in
the, 367 ,■ proliferoas oysts in the, 385 ; mye-
loid tomor in the, 471.
Necraemia : see Mortification.
Necrosis, 320 : and see Mortification ; of osse-
ous growths, 482 ; preceding cancer, 627.
Nerves : adaptation to atrophy, 99 ; healing of
divided, 201 ; atrophy after division, 117; in
granulations, 164 ; in adhesions, 257 ; fibrous
tumors in, 435 ; relation of painful tumors to,
419.
Nerve-cells, atrophy of, 98, note.
force, defect of, inducing mortification,
51, 315; changed in inflammation, 224 ; dis-
turbance of, initiating inflammation, 304.
Nervous system : effects of exercise, 28 ; influ-
ence on nutrition, 48, e. s. ; on secretion, 51.
— ' tissues, degeneration of, 116.
Neuralgia, with cancer, 552 ; with tumors, 420.
Neuroglia, 118 : see also Addenda.
Neuroma, 410, 429.
Neuro- pathological theory, 305.
Newport, Mr., on repair in insects, 128.
Nipple, hard cancer of the, 532.
Noli me tangere, 621.
Non-vamular parts, nutrition of, 48.
Nose, cutaneous outgrowth of, 405 ; epithelial
cancer on, 607; sloughing after bleeding, 45.
Nosology of cancers, 705.
Nucleated blastema, 142 ; in blood clot, 136 ;
ossification of, 178.
Nuclei: capacity for developmeot, 613; in
parts actively nourished, 61 ; of heart-fibres,
99; changes of, in cells, 141; stellate or
branched, in cartilage, 440, 447 ; erring, as
origins of cysts and tumors, 356, 358.
Nutrition : nutritive process, modes of, 26 ;
conditions of, 34 ; right state of the blood,
34 ; assimilation of the blood, 34 ; life of
blood, 34 ; diseases of blood, 35 ; symmetri-
cal diseases, 36 ; seats of election of diseases,
37 ; identity of specific morbid materials,
37. Excretory office of each part, 39 ; office
of rudimental organs, 39. Incorporation of
materials of the blood, 41 ; determining the
formation of certain structures, 41 ; favoring
the order of development, 42. Complemen-
tal nutrition, 42; simultaneous changes in
nutrition, 44 ; commensurate development,
44 ; constitutional disturbance, 44. Supply
of blood, 45 ; consequences of defect, 45 ; im-
bibition by tissues, 46 ; office of bloodvessels,
47. In^uence of the nervous system, 48 ;
of the mind, 50 ; injuries of nerves, 30 ; in-
eonstancy of effects, 52. HeiUthy state of
the part to be nourished, 55 ; assimilation in
diseased parts, 56 ; and in blood after diseases,
56 ; its precision, 58 ; and in the brain, 59 :
see also. Formative Process.
Nutrition, altered conditions of, in inflamma-
tion, 209 ; contrast of normal and inflamma-
tory. 296.
Nutritive repetition, 61.
Nymphse, outgrowths of, 405.
0.
0*Ferrall, Dr., case of fibro-cellular tumor, 410.
Ogle, Dr. John, on an intracranial cutaneous
cyst, 391, note.
Oily or fatty cy8t«, 369.
Open wounds, repair of, 123.
Orbit, cysts in or near the, 390 ; fibro-cellular
tumor in the, 414 ; medullary cancer in, 577 ;
osseous tumors growing into the, 476.
Organic affinity, 64.
form dependent on composition, 63.
Organisation of blood clot, 135.
Ormerod, Dr., on fatty hearts, 107; on inflam
matory products, 304.
Osseous tumors : in soft parts, 472 ; of bones,
473 ; chief kinds, 473 ; homology, 473 ; modes
of ossification, 474 ; cancellous, 475 ; ivory-
like, 476 ; of the skull, 476 ; sloughing, 478 ;
of the lower jaw, 479; of the toes, 479. Os-
seous growths of the superior maxillary and
other bones, 480 ; of the skull bones, 482.
Multiple osseous growths, 483 ; symmetrical
and hereditary, 483. Distinctions of the bone
in osseous and other tumors, 483 ; malignant,
646.
Ossific diathesis, 483.
infiammations, 253.
Ossification, in repair of fractures, 178 ; of car-
tilaginous tumors, 442, 443 ; of myeloid tu-
mors, 463.
Osteoid cancer : general nature, 646 ; seats,
646 ; general characters, 647 ; in lymphatic
glands, 648 ; microscopic characters, 649 ;
fibrous, 649 ; osseous, 649 ; affinities to osseous
tumors, 650; and medullary cancers, 567,
650 ; general pathology, 651 ; secondary dis-
ease, 651 ; cases, 652 ; characters of bone in,
484.
Osteo-chondroma, 435, note.
Osteomalacia, 111.
Osteophyte, 253.
Osteo-sarooma, 435, note ; 483.
Outgrowths : general characters of, 350 ; cu-
taneous, 405 ; fatty, 396 ; fibrous, 422, 433 ;
osseous, 472; multiple osseous, 483 ; of blood-
vessels, 161.
Ova, length of life, 33.
Ovary, cysts in, 375 ; their affinities with can-
cer, 388, 660 ; containing skin and its pro-
ducts, 389, 490 ; with teeth, 395 ; hard can
cer of, 540.
Overgrowth : see Hypertrophy.
Owen, Prof., on ossification, 87; on tubular
system in tendon, 48.
P.
Pachydermatocele, 406.
Pain, in mammary glandular tumors, 489 ; with
cancer, 551 ; nature of, in tumors, 418.
Painful subcutaneous tumors : general seats
and relations, 416 ; microscopic structures,
417; pain, 418; growth, 418; distinctions
from neuromata, 419 ; neuralgic pain, 420 ;
pain in other tumors, 421.
Palate, absorption of, under pressure, 80.
Palsy, wasting, 98.
Pancreas, cystiform dilatation of, 354.
Pancreatic tumor, 485.
PapillsB. new formation of, 205 ; cancerous,
601, 603, 620: and see Epithelial Cancer.
Paralyzed parts, nutrition in. 52 ; treatment of,
101.
Parotid, blood-cysts on or in the, 368 ; cartila-
ginous tumors on or in the, 454 ; cysts over
the, 361 ; cancer in, 587.
Pearly tumor, 393, note.
Pedunculated intracystic and other growths,
379, note.
Perforating ulcers, 311.
Pericardium, absorption of lymph from, 261.
Periodicity, in disease, 327, 335.
Periosteum : its injury in fractures, 176 ; im-
784
IVDBX.
porUae* of^ in formatloB of
DoU ; esoear liffng froB, 624 ; in aMdallarj
eaii0en,666.
P«ritoDeaiB, colloid esnoor of, 6&9.
Poritonitii, lymph in, 260, o. •.
PorpoioAtod morbid ehuurtt, 345.
Pononal modifleatioM of diauM, 835.
Pbalftoz of tho too. oveoof tamor on tko, 479.
PliAryiiz, fibroof polypi in the, 422.
Phllllpf , Mr., on Tuenlnr tomon, 508.
Phlobolitheo, in Tonooa tnmon, 500.
Phymntoid inbstaneo, 588, 713.
Phymofif , oiToet on the blnddor, 72 ; praooding
ennoor, 628.
PbyiaUdM, 612.
PhymliphorM, 612.
Pigment in melnnoid eaneer, 630, 643.
PimentAl degenermtion, 85 ; of fmnll arterioi,
113, note; degeneration of lymph, 262, 264,
274 ; in mnena-oelli, 244.
Pigmentary nnvi, liability to eanoer, 643.
Placet, morbid prodneU in certain, 684.
Plaitie force, 62.
and aplaitic lymph, 260.
Picnrify, lymph in, 247, 249, e. •.
Plenro-pnenmonia, mixed lymph in, 240.
Pneumonia, eifiifion of blood in, 232 ; lymph
in, 240.
Pointing of absocMee, 283.
Poiaoned wonndc, 303.
Poisons, morbid, 324, e. • : see Specific Dic-
oi;354.
jffocMi af^ 228.
oi;530; polypw cf the.
Beevrng caitilagiMw ta»>n, 457 ; ibroid
tUMTC, 51 U e. s. : myeloid tnmor, 471, 510 ;
prolilcffWf eyita, 386.
fibroid tamorc : caiea. 511.
Polypi, 402 ; flbroog, 422.
Porcellaneone change in bone, 280
Pott'e disease of spine, 720.
Predecessors, formation after plan ol^ 120.
Predisposition, meaning of, 676.
Pressors, effects of, on nutrition, 80 ; prodocing
slooghs, 312.
Primary adhesion, 149.
Prodromata of specific diseases, 335.
ProgeDitors imitated in ofidpring, 03.
Proliferoos cyvts, 373 ; in the ovarief, 373 ; with
broftd-based endogenoas cysts, 375 ; with pe-
danculated ojdts, 376 : intermediate forms,
376 ; in the cystic chorion, 377 ; their minate
structure and development, 378. With glan-
dular endogenous growthn, 379 ; in the mam-
mary gland, 380 ; method of intracyetic
growth, 380 ; consolidation and protrusion of
the growths, 382 ; general structure of the
growths, 382 ; their minute glandular struc-
ture, 382 ; their structure not evidently glan-
dular. 383. In the lip, 384 ; in the labium,
384 ; in various parts, 385. Recurring prolife-
rous cysts in the breast. 386 ; in cancers, 388.
Prostate gland, intracystic and detached
growths of, 342.
Prostatic-glandular tumor, 494.
Purpose, in relation to accidents, 120; in dis-
eases, 724.
Pus, 265 : see Inflammation and Suppuration ;
transference in blood, 700.
Pyogenic membrane. 269.
Q.
Quain, Dr., on fatty hearts, 92, e. s.
Quekett, Mr., on formation of new vessels, 162;
on ossification in cartilaginous tumors, 442 ;
on osseous tumors, 473, 477.
R.
Babbit-' ««^ri. inflamed, 210.
' Bcdiani, Dr., osi repair of oartUaga, 189 ; on
infiammatioa of cartilaga, 285.
: Beid, Dr. John, oa paralyaed mueloc, 101.
Bdaxi^g proesas ovor an aboeem, 283.
. Bemond of oueer, ofeeto of, 705 ; partial,
i 587-«.
{Bepair and reprodaetioa afUr ii^jarieo, 119;
adaptation ^ parts for ftstnre oTents, 120;
illactrations of the fbrmatlTa fovce, 120. Be-
pair of ciystals, 121 ; lis degreae in animals,
122 ; at diffsrent ages. 123 ; according to
amount of dcTolopment, 123. Bopair in aa-
teridsB, actlaia, and hydrm, 124 ; in tnbn-
laria, 127; gradual recovary of parfoction,
127. Bepair in InMCts, 128, and lisarda, 129;
In man and other mammalia, 129 ; general
dadnctiona, 130. Materials for repair,
132 ; distinction between sabcntlaiieoBS and
open i^jnrioB, 132. Methods of repair, 134.
Orpaniiation of blood, 134 ; ita shara in re-
pair, 138. Lymph, 139 ; Ita aanal dcTelop-
menta, 140 ; grannlation-calla, 140 ; on boast,
142 ; nocleated blaitoma, 142 ; daralopaMnta
of ftbro-oellttlar tlaane, 144; from mizad
prodncta, 144.
of open wonnda, 146 ; 5jf immmUaSM
Kfsttfft, 146. Dr. Maeartney*a account, 146 ;
deaeriptlonof caaea. 146; and experiments,
147 ; the beat healing, 148 ; eonditiona ne-
oesaary for it, 148 ; 5y yrimarf adiUuoH, 149.
Hnnter*a account, 149; exampleaof the pro-
cess, 150 ; its quickness, 150 ; by grannlatvm^
151; glazing of an open wound, 162; ioaction
after injury, 153; granulations forming, 154:
afflux of blood, 154; comparison with inflam-
mation, 154: effusion of reparative material,
155; its vascularisation, 155; minute struc-
ture, 156 ; without suppuration, 156 ; devel-
opment, 156 ; arrest or error, 157 ; and dis-
eases, 157; contraction, 173; chemical
changes, 159 ; formation of new vessels, 160 ;
three modes, 160, — that by outgrowth, 161 ;
by channelling, 162 ; general arrangement
of vessels, 162; structure, 164; relaiiou:! to
organisation, 164 ; development of nerves
and lymphatics, 164; by ucottdttry aiihetion,
164; its plan, 165; examples. 166; condi-
tions necessary, 166; bytcabbing^ 166; its
process with blood, 167 ; with pus, 167 ; sup-
puration and scars (see these words).
fractures, 1 75 ; nature and extent of
injury, 175; extravasation, 176 ; inftamma-
tion, 176 ; period of calm, 176; commence-
ment of repair, 177; immediate union, 177;
reparative material or callus, 177; its mdi-
mental state, 177 ; ossification through fibrous
tissue, 178 ; through cartilage, 178 ; charac-
ters of the new bone, 179 ; position of the re-
parative material, 180 ; provisional or en-
sheathing callus, 180; interior callus, 181;
intermediate callus, 182 ; differencei of repair
in man and animals, 184; modelling after the
repair, 185 ; repair of compound fractures,
187 ; times of the stages of the repair, 187 ;
failure of repair, 187 ; falae joints, Ac., 187.
Repair of cartilage, 189; of tendons, 190; dis-
INDEX.
735
advantages of open wounds, 191 ; effect of
dividing the sheath of connective tissue, 191 ;
repair after subcutaneous division, 192; re-
traction of upper portion, 192 ; extravasa-
tion, 192 ; exudation, 192 ; reparative ma-
terial, 193 ; its development, 193 ; imperfec-
tion, 194; strength of the union, 195. Of
muscles, 195. Of arteries and veins, 196 ;
with small wounds, 196 ; with partial divi-
sion, 196 ; with complete division, 197 ; con-
traction and retraction, 197 ; after ligature,
198; inflammation of the tied end, 198;
contraction of the part above it, 199 ; changes
in the stagnant blood, 199. Of nerves, 201 ;
oases of primary union, 201 ; secondary
union, 203 ; formation of new fibres, 204 ;
repair of nerve-centres, 204. Of skin, 205 ;
new formation of papiilsd and cuticle, 205 ;
relation to inflammation, 206.
Repetition, nutritive, 61.
Reptiles, repair in, 129.
Resolution of inflammation, 261.
Reticulum of cancer, 701.
Rheumatism, localization of, 303.
Rickets, 112 ; effect of on tibisB, 77.
Right state of blood, 34.
Ringing effects of, 41.
Roberts, Dr., on wasting palsy. 98.
Robin, M., on vessels in erectile tumors, 499 ;
on epithelioma of kidney, 596.
Rodent ulcer, 621.
Rokitansky, Prof., on the formation of cysts,
355 ; on dendritic vegetation in villous can-
cer, 655 ; on degeneration of arteries, 113 ; on
erectile cavernous tumors, 504, 575 ; on endo-
genous cells in cancer, 614 ; on inflammatory
products, 236 ; on stroma of cancer, ^., 574 ;
on tubercle, Ac., 708.
Rolleston, Prof., on complementary nutrition,
44 ; on appendicular structures to the testis,
372
Rosenmiiller, organ of, 874.
Rudimental organs, purpose of, 39.
S.
Salivary glandular tumors, 454, 456.
Sanguineous cysts, 367 ; their various contents,
367 ; in the neck, 368 ; in the parotid gland,
368; internally fasciculated, 368; formed
from dilated veins, 369.
Sap, effects of accumulation, 41.
Saponification of cancer, 588.
Sarcoma, albuminous, 515 ; gelatinous, 402,
454, note ; sero-cystic, 373, 379.
Scabbing, healing by, 166 : and see under Re-
pair.
Scars, maintenance and growth of, 56 ; their
contraction, 173; improvement and gradual
perfection, 174; loosening, 174; warty and
cancerous growths on, 623.
Schroeder van der Kolk, Prof., on lymphatics
in adhesions, 256 ; in cancers, 566 ; on tu-
bercle, 709.
Scirrhous cancer, 519 ; usual form in the <
breast, 520 ; usual state of the gland, 520 ;
hardness, 521 ; size and shape, 521 ; adhe-
sion and retraction of tissues, 522 ; cut sur-
face, 522; mixture of cancerous and natural
structures, 524 ; wasting of natural tissues,
525; cancer juice and stroma, 525; infiltra-
tion of cancer-structures, 525; cells, Ac.,
526 ; degenerate^ structures, 527 ; degenerate
normal structures, 527 ; reticulum, 529 ; fi-
brous tissue, 530. Vartetie* : acute and
chronic, 531 ; of the nipple and skin, 531.
In the lymphatic glands, 533 ; in the skin,
535 ; muscles, 536 ; bones, 537 ; ifUestinal
camtl, 538 ; mingled forms, 539 \fhrous can-
cer, 540 ; in ovaries, Ac, 540. Fathology :
influence of sex, 442 ; age, 542 ; of menstrua-
tion, 543 ; hereditary disposition, 544 ; in-
jury, 545 ; general health, 545 ; first appear-
ance, 546 ; growth, 546 ; multiple growths,
547 ; ulceration, 547 ; superficial, 547 ; sub-
stantial, 548 ; softening, 549 ; arrest and
healing, 550 ; in connection with phthisis,
550 ; shrivelling, 551 ; pain, 552 ; cachexia,
553 ; primary and secondary, 553 ; multipli-
cation, 553 ; duration, 554 ; effect of age,
555 ; effect of removal, 557 ; recurrence, 557 ;
second recurrence, 557 ; rules concerning
operations, 559.
Scrofula, relation to tuberclous disease, 715.
Scrofulous matter, 260, 263, 715.
Scrotum, cancer of: see Epithelial Cancer;
fatty tumor in the, 399 ; fibro-cellular tu-
mors in the, 409 ; hypertrophy of, 405.
Sebaceous and epidermal cysts, 391 ; heredi-
tary origin, 391 ; twofold formation, 391 ;
various characters, 392 ; of the walls and of
the contents, 392 ; ulceration, 394 ; fatal
case, 394 ; protruded contents becoming
vascular, 395 ; connected with epithelial can-
cer, 607.
Secondary adhesion, 152.
cysts, 375, e. s.
Secretion, influence of nervous force on, 51.
Semi -malignant tumors, 473, 517.
Seminal cysts, 370 ; their spermatozoa, 371 ;
connections, 371 ; diversity of contents, 372 ;
degeneracy, 372 ; spermatosoa in the sac of
tunica vaginalis, 372.
Senile gangrene, 313.
SequelsB of diseases, 335.
Sero-cystic sarcoma, 373, note ; 379.
Serous cysts : their contents, 359 ; seats, 359 ;
in the neck, 360 ; connected with the thy-
roid gland, 361 ; transformations of vascular
tumo.rs, 36 1 ; with viscid contents and cho-
lesterine, 362; near the gums, 362; in the
mammary gland, 363; dilated ducts, 363;
autogenous cysts, 363 ; confusion with mam-
mary cancer, 364 ; large single cysts, 365.
Serpent-venom, 331.
Sex, influence of, in cancers : see Cancer, gene-
ral pathology.
Sexual characters, related development of, 42.
Shifting of tumors, 399, 514.
Shortening of bones, 78.
Sibley, Mr., on colloid cancer, 660, 662; on
villous cancer, 654 ; on multiple fibrous tu-
mors, 667.
Simon, Mr., his observations encysts, 358; on
extension of cancer, 697 ; on morbid poisons,
329, e. s. ; on scrofula, 716.
Simpson, Prof., on congenital cysts, 360; pn
reproduction of limbs, 123.
Simultaneous changes in nutrition, 42.
Skeleton of cancers, 574.
Skin, cancer of : see also Epithelial Cancer;
hard cancer of the, 532, 535 ; intracystic for-
mation of, 390 ; outgrowths of, 405; repair
of wounds of, 205 ; reflected, union of, 146 ;
tubercle in, 718.
Skull, hypertrophy of, 73, e. s. ; atrophy in old
age, 108 ; cartilaginous tumors of the, 451 ;
granulations on the, 154, 165; myeloid tn*
736
INDEX.
mor of tbe, 467 ; osseoas growths on the,
482 ; osseous tamors on or in, 476.
Sloagh : see Mortification.
Smith, Dr., on neuroma, 420.
Snellen, experiments on trigeminal nerve, 54,
note.
Soft oanoer : see Medullary Cancer.
Softening, in infiammation, 276 ; over an ab-
scess, 283 ; of cartilaginous tumors, 445 ; of
fibrous tumors, 429 ; of cancers, 703 ; of tu-
bercle, 711.
Solution of ulcerating parts, 290.
Soot-wart, 629.
Spallansani, on reproduction of parts, 123.
Specific diseases : distinction, from common
diseases, 322 ; specific characters, 323 ; plan,
or construction, 323 ; causes, 325 ; local and
general phenomena, 326 ; disproportionate
cause and effect, 326 ; disproportionate local
and constitutional states, 326 ; symmetry,
Ac, 326; self-augmentation, 327; transfor-
mation, 327 ; periodicity, 328 ; theory, 328 ;
its application, 330 ; introduction of morbid
materials, 330 ; their effect on tissues, 330 ;
example of insect-bite, 331 ; local aptness
for disease, 332 ; effect and changes in blood,
333 ; increase, 333 ; transformation, 334 ;
combination, 335 ; separation, 336 ; charac-
teristic formation of new bone in, 254 ; mor-
bid materials, incorporation of, 302.
Sphacelus : see Mortification.
Spine, cartilaginous tumor on the, 444, 451.
Spinal cord, atrophy of, 117 ; effects of injury
of, 51 ; repair of injuries of, 204.
Spleen-like tumors, 463, note.
Spurs, effect of transplantation, 69.
Stagnation of blood, 218, 224, 312.
Stanley, Mr., on pulsating tumors, 565 ; on
scrofulous disease in bone, 720 ; on necrosis,
821 ; on removal of exostoses, 473.
Starch, presence in textures, 89, 90.
Stasis, 224.
Steatoma, 396 : see Fatty Tumor.
Stilling, Dr., on repair of bloodvessels, 199.
Strangulated parts, sloughing, 312, 318.
Stricture, cancerous, of intestine, 539.
Stroma of cancer, 525, 531, 564, 574, 655, 693.
See Scirrhus, Ac.
Structure dependent on composition, 63.
Struma, relation to tuberculous disease, 715.
Subcutaneous injuries, repair of. 132.
ntevi, 497, 505.
tissue, cysts in the, 390 ; medul-
lary cancer of, 579 ; fibrous tumors in the,
430 ,- painful tumors in the, 416.
Submaxillary gland, cartilaginous tumors on
the, 454.
Submucous tissue, fibrous tumors in the, 429.
Suppuration : in repair, 169 ; characters of
pus, 169 ; origin of pus, 266; pus-cells, 169;
liquor puris, 172; relation of the cells to
those of granulations, 170; their imperfec-
tion or degeneracy, 171 ; the same of the
liquor puris, 172; which may be a liquefied
blastenin, 172; use of pus, 172. Inflamma-
tory, 204, 282 : and see Inflammation ; of
cancerous glands, 580, 618.
Syme, Mr., on exostosis, 474 ; on influence of
periosteum, 179; on transition-tumors, 509.
Symmetrical diseases, 36 : osseous tumors, 482,
Sympathetic nervous system, influence on nu-
trition, 54.
Synovial cysts, 365.
Syphilitic ulcers, Ac, 324, 327, 333, Ac.
T.
Teeth, life of, 32 ; absorption and ^eetion of
fangs, 59 ; induration of, 280, note ; over-
growth of, in rodents, 80 ; separation of, in
old age, 321 ; in cysts and tumors, 395.
Teeth-pulps, effects of inflammation on, 287.
TelangeiecUsis, 495, 499.
Tendons, healing of divided, 190.
Testicle, inflamed after stimulus of the urethra,
225 ; cartilaginous tumor in, 458, note ; car-
tilaginous and cancerous tamors in the, 459 ;
cartilaginous and fibro-eystic tumor in the,
461 ; fibro-cellular tumor in the, 413 ; fibro-
cystic tumor in the, 427 ; hydatid, 427 ; me-
dullary cancer of, 565, 576, 586 ; osteoid
cancer of, 646 ; tubercle in the, 714.
Thickening, by inflammation, 250; of skull,
74.
Thrombus, 200.
Thyroid gland, intra-cystie and detached
growths of, 341, 342 ; tamors, 494; cysts in
or near the, 361.
Tibia, lengthening of, 77 ; oartilaginoas tumor
on the, 448; myeloid tumor in the, 463;
great osseous tumor of the, 476.
Time, an element in disease, 328 ; in adjust-
ment of organic processes, 33.
Tissues, influence of, in inflammation, 339.
Toe, osseous tumors on the great, 479.
Tongue, epithelial cancer on the, 606 ; fatty
tumors in or near the, 400 ; fibro-oeUalw tu-
mor in the, 414.
Transformation, in disease, 327 ; of diseases in
hereditary transmission, 676; of nataral
structures into cancerous, 688.
Transition tumors, 509.
Transplanted parts, fatty degeneration of, 260.
Traumatic gangrene, 317.
Travers, Mr., on healing in the frog^s web, 153,
154 ; on inflammation, 208.
Trembley, experiments on hydrae, 124.
Treviranus, on the excretion-ofiice of each part,
38.
Trigeminal nerve, influence on nutrition, 53.
Tuberculous disease, incompatible with can-
cer, 674, 551.
Tubercle, 707 ; type in the lungs, 707 ; gray
and yellow forms, 707-8 ; minut« structure,
70!^ ; origin in epithelial cells, 709 ; origin
of, in connective-tissue corpuscles. 710;
abortiveness, 711 ; degeneration, 711 ; soft-
ening, 711 ; discharge by ulceration, 713;
cavities and ulcers, 712; tuberculoid sub-
stances, 713; scrofula, 714. In lymphatic
glands, 716 ; in integuments, 718; in bone^,
719. Likeness to inflammation and to can-
cer, 721.
, cancerous, on the face, 621.
Tumors : see the specific names — e. f. S^rons
cyst, Fatty tumor, Ac. ; contracted with
hypertrophies, 338 ; with product* of in-
flammation, 338; their property of growing,
339 ; nutrition, irrespective of the rest of
the body, 341; aji parts overgrowing, 341;
cessation of growth, 341 ; Malig}uint, gene-
ral characters of, 343, e. s. ; innocent con-
trasted with malignant, 347 ; recurrent, dis-
tinctive characters of, 347, 509; proportions
assigned to injury, 348 ; supposed origins of,
348 ; classification of, 343, .^49, Ac. : divi-
sion and nomenclature, 349 ; classification of,
objections to, 351 ; distinguished from inflam-
matory products, 298.
INDEX.
737
Tanica raginalis, ooniaining seminal flaid, 372.
Tarck, Dr., on atrophy of the columns of the
spinal oord, 117.
U.
Ulcer, cancerous, 547, 608 ; cancroid, 620 ;
perforating, 311 ; of stomach, 622; rodent,
621 ; specific, 324, Ac. ; becoming seats of
cancer, 311.
Ulceration, 288 : and see Inflammation ; in
sloughing, 319 ; liability of Isertain tumors
to, 344 ; of cancer, 547 : and see Cancer,
general pathology; contrast of cancerous
with simple, 345 ; tuberculous, 718.
Ulna, increased after injury of radius, 78.
Union, immediate, or by the first intention,
134 ; by adhesion, 146 ; of granulations, 165.
Urethra, vascular growths in the, 505.
Urinary bladder, hypertrophy of, 70, 72 ; po-
lypus in the, 404 ; villous cancer in, 654.
Uterine growth and tumor, contrasted, 338.
Uterus, development in pregnancy, 66 ; fatty
degeneration after parturition, 107 ; growth
of, around tumors, 338 ; tumors imitating
the structure of, 338 ; epithelial, cauliflower-
cancer of, 619; fleshy tubercle of, 422; fib-
rous tumors in, 425, 429 ; fibrous polypi of,
422 ; cysts in fibrous tumors in the, 427.
V.
Vaccination, effects of, 303.
Vaccine virus, effects on blood, 57.
Vagina, fibro-cellnlar tumors by the, 411 ; epi-
thelial cancer of, 619.
Vascular and non-vascular parts, 47.
tumors : synonyms, 495 ; likeness to
erectile tissue, 496 ; chief kinds, 497 ; capil-
lary, 497 ; arterial, 500 ; venous, 502 ; gene-
ral characters, 504 ; enlarging blood spaces,
504 ; tissues affected, 505 ; general charac-
ters of subcutaneous nsBvi, 505; cysts in, 507,
361 ; relation to cancers, 508.
Veins, healing of injured, 196 ; dilated into
cysts, 369 ; cancer in, 673, 700.
Venom of insects, Ac., 331.
Venous vascular tumors, 502.
VertebrsB, cartilaginous tumors on the, 444,
451; tuberculous disease in, 719.
Villous cancer : general characters, 653 ; den-
dritic growth, 655 ; bloodvessels, 656 ; struc-
ture, 657.
Virchow, Prof., on amyloid degeneration, 89 ;
on oanlifiower excrescence, 619; on eochon-
drosis prolifera, 474 ; on fatty degeneration,
91, e. s. ; on inflammation of muscles, 285 ; of
the cornea, 286 ; on malum senile, 108 ; on
neuralgia, 118 ; on obstruction of cerebral ar-
teries, 1 16 ; on origin of pus, 266, cancer,
689, and tubercle, 710, from pre-existing tex-
tural elements, notes ; on rarefaction of
bones, 538 ; on tubercle, 709, 710, 714 ; on
vessels in erectile tumors, 503.
Virus, effects of, 302.
W.
Waller, Dr., on formation of new nerve-fibres,
204 ; on effects of division of nerves, 117.
Walshe, Dr., on cancer, 520, 561, 678, 680, Ac.;
on rarefaction of bones, 538.
Wardrop, Mr., case of healing by scabbing,
166 ; on medullary cancer, 577, 645, Ac.
Warren, Dr., on lepoides, 628 ; on colloid can-
cer, 662.
Warts, becoming seats of cancer, 628.
Warty growths, 601, 620; on scars, 623.
cancer : see Epithelial Cancer.
Wasting palsy, 98.
Wearing out of parts, 27.
Williams, Dr. C. J. B., on varieties of lymph,
235, note.
Dr. Robert, on morbid poisons, 329, e. s.
Wood, Mr. Wm., on painful subcutaneous tu-
bercle, 416.
Wormian bones, in hydrocephalic skulls, 73.
Wounds, repair of, 132, e. s. : see Repair.
Wright, Dr. S., experiments on Actinia, 126.
Wrist, osseous tumor on the, 472.
X.
Xanthose, 463.
Z.
Zoology, comparison of nosology with, 705.
Zwicky, Dr., on organization of blood, 134, 199.
48
September, 1870.
OF
WORKS ON MEDICINE, SURGERY, DENTISTRY,
iND THE COLLATERAL SCIENCES.
PUBLISHED BY
LINDSAY & BLAKISTON, PHILADELPHIA.
CONTENTS.
Lindsay & Blakiston's Ytsittno . List for 1871, see redaction in prices.
Tanner-8 Practice op Medicine, 6th American Edition (Just iReadv.)
Reprinted from the 6th Enlarged and Improved London Edition.
Meios and Pepper's Practical Treatise on Diseases of Children, the
Fourth Edition, tery much enlarged.
Cazbaux's Great Work on Obstetrics, the most complete Text-Book
on the subject now published.
Aitken's Practice, from the 5th enlarged London Edition, with additions
by Dr. Clynier equal to 500 pages of the English copy, made with
special reference to the wants of the American Practitioner.
Trousseau's Clinical Medicine, 3 volumes (the third volume just ready.)
Price reduced.
Works py XiioN^L S. Beale, F.R.S., Prices reduced.
New Books Just Ready and in Preparation.
Alphabetical List of Lindsay & Blakiston's Medical Publications, with
brief Critical or Descriptive Notices.
Dental Works published by Lindsay A Blakiston.
Scientific Books do. do. do.
The New Sydenham Society's Publications, a Revised List, with ao-
nouncements for 1870.
American and British Periodicals supplied by Lindsay A Blakiston.
Anatomical Maps and Plates.
English Books RIecently Imported.
Condensed List of Lindsay & Blakiston's Publications!,
LINDSAY Sc BLAKISTON, in isBuing a reyised Catalogue of their Mediea!
Publications, desire to call the attention of the Profession to the reduction thej haye
mnde in the price of their Visiting List for 1871. This little work haying become
an almost indispensable companion to the Practising Physician, thej wish to extend
as far as possible its usefulness by keeping the price down as low as the increased cost
of manufacture will permit. They haye also, in order to meet to some extent the
demand for lower prices, reduced the priae of Dr. Bialb*8 books of Tboubsiau's
Clinical Medicine, the 8d yolume of which has just been issued, and of many other
books in their Catalogue, and also their rates for the importation of PoBiioic Books
and Periodicals.
*
JKSr Okobbs for any Medical Books, whether published in the United States or
otherwise, and not contained in this Catalogue, will be executed promptly, and at i\k%
lowest prices.
PRICES REDUCED OF
Lindsay & Blakiston's
PHYSICIAN'S YISITING LIST.
NOW EEADY FOE 1871.
**Tbe simplest of all the visiting lists published, it must continue to hold, what it
now has, the preference over all other forms of this indispensable companion for the
Physician:" — New York Med. Journal.
003SrTDE33SrTS.
1. Table of Sigrns, or Gnide for RegisteriDg Yisits, En- 7. Momoranda pagm
gageinent«, Ac. 8. PafCM for Addresn
2. An Almanac for 186S.
3. Mnrshall llairs- Ready Method in Asphyxia.
4. Puisona and their Autidotes.
6. Table for Calculating the Period of Utero-OestatloD.
6. The Visiting List arranged for 25, 60, 76, or 100
Patients.
7. Memoranda pagvs for eTpry month In the year.
8. Paget for Addresses of Patients, kc
9. ** Bills and Accounts asked for and d»
livered.
10. ** Obstetric Engagemeoti.
11. ** VNcciuitlon.
12. ** Recording Obstetric Caaes, Deaths, vU
for Oenend Memoranda.
SIZES AND PRICE.
For 26 Patienti weekly. Tncki, pooketo, and pencil, . • • . $1 00
60 *• ** *• ** *'*■•••••• 1 26
76 •* «• " •* " 1 60
100 " ** «* ** " 8 00
»o " "2'oi«{js',«ir} " «-»
Also, AN INTERLEAVED EDITION,
for the use of Country Phyticiant and others who compound their own Prescriptions,
or furnish Medicines to their patients. The additional pages can also be used for Spedd
Memoranda, recording important cases, &o., &c.
For 25 Patients weekly, interleaTed, tucks, pockets etc., . . . . $1 60
60 •* " " «. i« «*....! 71
60 " «' 2 vols / ^*"- ^ ^^^^' I «« «« 8 00
**" ^ ^**^" \ July to Deo. / .... 8 00
This Visiting List has now been published for Twenty Years, and has
met with such uniform and hearty approval from the Profession, that the
demand for it has steadily increased from year to year.
The Publishers, in order to still further extend its circulation and useful-
ness, and to keep up the reputation which it has so long retained, of being
THE CHEAPEST AND BEST,
as well as the Oldest Visiting List published, have now made a verj/
considerable reduction in the price.
It can be procured from the principal booksellers in any of the large
cities of the United States and Canada, or copies will be forwarded by mail,
free of postage , by the Publishers, upon receipt by them of the retail price
as annexed.
In orderino; the work from other booksellers, order
Tfnf7::^[/ S:B1a1cisfo7i\H Phf/sician^^ Visiting List.
And in all oapcs, wliether ordering from the Publishers or otherwise,
specify the size, style, &c., wanted.
LINDSAY & BLAKISTON, PubUshers,
25 South Sixth St., Phlleidetphta.
"The leading feature of this book is its essentially practical charcLcter^^^
London Lancet.
Tanner's Practice of Medicine.
FIFTH AMERICAN. FROM THE SIXTH LONDON EDITION.
ENLAUQED AND TIIOHOVGULY liEVISED.
JUST HEADY.
THE PRACTICE OF MEDICINE, by Thomas Hawkes Tanner,
M.D., Ft*llo\o of the Royal College of Physicians, Author of Tanner's
Practical Treatise on the Diseases of Children, &c., dec. Fifth Ame-
rican Edition, with a very large Collection of Formulae. One VulumCf
Royal Octavo, containing over WOO jyages.
Price, hantlsomely bound in Cloth, . . $6 00
" " " Leather, . . T 00
003SrTE3srTS.
Part 1. General DiseMeB.
" 2. Fevers.
8. Venereal Diseases.
4. Diseases of the Nervous System.
6. Diseases of the Organs of lieypi-
ration and Circulation.
6. Diseases of the Thoracic Walls.
7. Diseasesof the Alimentary Canal.
8. Diseases of the Liver.
9. Diseases of the Pancreas and
Spleen.
«
«i
i<
it
<t
Part 10. Diseases of the Abdominal Walls.
'• 11. Diseases of the Urinary Orgaps.
'* 12. Diseases of the Uterine Organs.
13. Diseases of the Skin.
14. Diseases of Cutaneous Append-
ages.
15. Diseases of the Bloodvessels.
10. Diseases of the Absorbent System.
Appendix of Formulce
General Index.
it
*i
K
l(
'* The rapidity with which edition aff er edition of this work has appeared and dis-
appeared is, on the whole, a true test of its merits. The fifth edition was, we believe^
a very large one, yet the book was for some time out of print before the present one
eould be prepared. Dr. Tanner has chosen his title well; his work is essentially ont-
on the practice of medicine in its widest sense, and it is in what relates to pure prae*^
tice, as contradistinguished from the theory of medicine, that the book is strongest;
for it has been the author's aim to collect everything he could think of which would
aid the practitioner in the discharge of his duties. But it is not to men engaged in
the active discharge of the duties of their profession alone to whom the book is wel-
come. With the student, preparing himself to enter upon these duties, the book has
long been a favorite, chiefly, we believe, from the lucidity of its style and the character
of its substance. Other books there are, more eloquent and more recondite, but none
excel Dr. Tanner's work in these important features. All that is necessary to know
is here, disposed in such a manner as to admit of the readiest reference, and of being:
most easily retained in the memory. Our limits will not admit of an extended review*
which would be out of place with regard to a book practically established as a standard.
It carries its own recommendation, and is its own best passport to general use. It haa
been the result of very great labor — labor well spent; and it appears in a form which
is creditable to its publishers as it is pleasing to those who have to use the book. —
Britiah and Foreign Medico- Chirurgital Review, April, 1870.
•* Dr. Tanner's works are all essentially and thoroughly practical, — he never for ona.
moment allows this utilitarian end to escape his mental view. He aims at teaching how
to recognize and how to cure disease, and in this be is thoroughly successful. It ia
indeed a wonderful mine of knowledge." — Medical Tiwut and Oazette, July^ ]8(>0.
MEICS AND PEPPER ON CHILDREN.
" Th<; most thorough ami Practical Work on the subject now of/ore Oie
Profession."
Meigs and Pepper's Practical Treatise on
the Diseases of Children.
ronrth Edition, thorongbly EeTiBed and greatly Enlarged.
By J. Forsyth Meios, M. D., Fellow of the College of Pbysinann of
Philadelphia, &c., (fa., and William Peppek, M. D.. Physician to Hit
Philadelphia Hospital, dc-, <ic., forming a, E-oyal Octavo Volume of
over 900 pages, Price, bound in Cloth, . . . ffi 00
" " Leather, , . . 7 00
Dr. Msijts" work hsa been out of print for Bouie years, The rapid sale of the IbtM
previoua oiiilioDs, and ihe grtal tlemAnd for » new editiao. i« sufficient evidence of iii
grout ]iopulnrity ; wUtle the very large pmcliee of nijiQy jBar»' alBQiling of Ihe mithoT
[q lbs (peoitUtjr of '■ DiseageB of Children," imparls to it a tbIiig oneqiiallei]. prabablj-.
by any other vorlt on the same lutgeet noif before (he ProfeMion. TliU present «^ici an
has been almost eotiretj rewritlGn and rearrnnped, and no effort or lubor but been
apured by either Drs. Meigs or Pepper, to irmlce it represent fully in its most adianoed
natu the prenent condition of MsdioiDe at applied lo Children's Diseages,
The ei]lire Rork has been Eubjccied to careful reTi«ion. Seiernl of tlie artlclea. M
those 00 EclDtupsia, Chorea, and Parasitia Shin Disennes. hare heeu miiuii c
and albers, ns lh« TariouB articles on the Diseaeos of the Stomach and Inlest
that on Eciemaloan Affections, entirely rewritten. In addition, arUcles lii
added upon the following important aubjecls :
Dlsenses of the Heart.
CyanoBis.
Diseases of (he Csecum and Appendi:
Intuasusoepiion,
Chronic Hjdroocphalna.
M*«i
Facial raralysia.
Rheumatism.
Diphtheria.
Mumps.
Bickett.
Tuberculosia.
Atrophic Infonlilc PatBlysis. InfuntiU Syphilis.
ProgrcsaiTe Paralysis with apparenl Hy- Typhoid Feier.
perlrophy of the MiiscleB. ScieroBJS.
The new matter thu9 added amounts lo nearly 200 pages, II has been the effort of
the authorg, while endcnvoring to tuHka the work fully represent the slate of our knoitl-
edgs upon the subjects treated of, lo retain its eminently praelical character; and nith
this view, an uniisuallr large amount of spnae bat been dcTOtvd to the congSderation
of tbe troaloient of each disease,
"This is the fourth edition of Meigs on Diseases of Children, itreatly enlarg:ed and
iniproved by chapters upon a large number of new aubjects. and ¥lsc by a Tery copiaua
index, which facilitates referencB, and makes the work mare a«rt>aeablo to the Prac-
titioner, As now enlarHc'd. it ia one of the moat complete and aomprchvueiio works of
its eUss. and will meet ine wants of the Professianin iliis department meat admirably,'
— Jiuffah Mid. and Sarg. Jaurnal.
" It Is tery oomprchcnsiTe, and embraces most of ibe maladies incident to childbood
and Inlkaey. Ws eonsider il a vary safe, reiiable. and suggestiTB gnide, being quite targe
■nd full in detail, embracing almost everythiug pertaining to the Bulyecl, making il a
Tcrj uteful book both for ruference and atudy."— ilidieal AnkwH.
" It forms the most complete and comprehcnsiie work upon Uie diseases of ehildrvn
published in this country. It has for years been one of the standard auihoritioa, and
in its present enlarged form will still more command altcnliuu. Il presenla the laleu
riews of pathology and Ircalment, and Inkes into considernliOD many siil>iei:ls wbiuk
were entirely omitted in the previous editions." — Ditroil Journal of Mi4mnt, ft.
"Il is BHtlihctary to note that the authors bave brought op their work lo the lerel
•f Ibe paibological knoniedge of Ibe day. and (hat their iherapeulical sotiona are
squally ad tanccd. The aiilhors are enrolled among the more enlightened tberapeut-
ists of our time. One eannol fail to be struck Ihroiighoiil Ihe (realise witb lb* Tttj
judicious advice given by the authors on various points of traalnieol. The Work, n* •
whole, is emiiled to rank with Ihe best." — Midical Reptriory.
Cazeaux's Great TVofk on Obstetrics.
THE MOST COMPLETE TEXT-BOOK NOW PUBLISHED.
GREATLY ENLARGED AND IMPROVED.
ff
CONTAINING 175 ILLUSTRATIONS.
A Theoretical and Pnctical Treatise on Midwifery, including the Diseases
of Pregnancy and Parturiticn, by P. CAZS^yx, Member of the Imperioi
Academy of Medicine ; Adjunct Professor in the Faculty of Medicine of
PariSf etCf etc. Revised and Annotated by S. Tarnixe, Adjunct Pro-
fessor in the Faculty of Medicine of Paris; Former Clinical Chief of the
Lying-in-Hospital, etc., etc. Fifth American from the Seventh French Edi-
tion. Translated by \Vm. R. Bullock, M. D. In one volqme Royal Oc-
tavo, of over 1100 pages, with numerous Lithographic and other Illustra-
tions on Wood.
Price, bound in Cloth, bevelled boards, . $6.50
" " Leather, 7.50
«
M. Caseauz's Great Work on Obstetrics has become classical in its character, and
almost an Encjclopoddia in its fulness. Written expressly for the use of students of-*
medicine, and those of midwifery b8pecially, its teachings are plain and explicit, present-.
ing a condensed summary of the leading principles established by the masters of th^
obstetric art, and such clear, practical directions for the management of the pregnant,
parturient, and puerperal states, as have been sanctioned by the most authoritative
practitioners, and confirmed by the author's own experience. Collecting his materials
from the writings of the entire body of antecedent writers, carefully testing their correct- ■
ness and valqe by his own daily experiencev and rejecting all such as were falsified by
the numerous cases brought under |his own immediate observAtion, he has formed out of
them a body of doctrine, and a system of practical rules, which he illustrates and enforces
in the clearest and most simple manner possible.
OPINIONS OP THE PRESS.
"It is nnqnestioDably a work of tho highest excellence, rich in information, and perhaps faller in details
than any taxt-book with which wt are aoqaainUd. The author haa not merely treated of every one!*
tiqn which relates to the business of parturition, but he has done so with judgment and ability."
BriUak and Foreign Medi^o-Ckirurgical Review,
" The translation of Dr. Bullock is remarkably well done. We can recommend this work to these
especially interested in the subjects treated, and can especially recommend the American edition."
Medical Timee and Oatette,
** The edition before us is one of unquestionable exoollenee. Erery portion of it has undergone a .
thorough rerision, and no Httle modification ; while copious and inlportant additions have been made to
nearly every part of it. It is well and beautifully illustrated by numerous wood and lithographic
engravings, and, in typographical execution, will bear a favorable comparison with other works of the
same elass." — American Medical JoumaL '*
** In the multitudinous collection of works devoted to the propagation of human beings, and to the
details of parturition, none, in our estimation, bears any comparison to the work of Caxcaux, in its
entire perfcctnoM; and if we were called upon to rely alone on one work on aooonchments, our choloe
would fall upon the book before us without any kind of hesitation." — Weet. Jour, of Med. and Suryer^.
" We do not hesitate to say, that it is now the most complete and best treatise on the subject in the
English language."— Huffalo Medical Journal,
"We know of no work on this all-important branch of our profession thi^t we ean recommend to Uie
student or practitioner as a safe guide oefore this." — Chicago Medical Journal,
" Among the many valuable treatises on the aoienoeand art of obst«trioi, the work of Oaseanx standi
pre-eminent." — St. Louie Med, and Surg, JoumaL r
** M. Caieanx's book is the most complete we have ever seen upon the subject It is well translat*^
and reflects great credit upon Dr, Bollock's intelligence and industry." — W. A. MedieO'Ckirtirg, Bwiem
' The Eepresentative Book of Medinal Science^ — LoSDos LAScrr.
f Aitken's Science and Practice of Medicine.
SEOOHD AMEBIOAlf FROM THE riTTH LONDOS EDITION.
I Containing ADniTiONS equal to 500 pngee of the Engliali Edition, pre|)ared bj
the American Editoh with Special Ruference lo the
wftntB of the American PRACxiTioNEa.
The Science and Practice of Medicine. Bij William Aitrek, M.D, Second
Amnrican from Uie Fifth Enlarged London Ediiion, with. Addiliont bij
Meredith Cltmer. M.D.. lale- Professor of Che Inttilutea and J'rartite of
Medicine in the UftiuemUy of Ntw York. Phyaivian to the Philadefplni
Sospital, etc. In 2 Volumes Royal Octavo.
Wiih A COLORED MAP. a LITHOGRAPHIC PLATE, Mid ONE HCKDRED AND
THIRTY ILLUSTRATIONS ON W001>.
Price, bouDd in Cloth, bevelled boards
" " Leather, .
$lS.fiO
14.00
Ftltoen rnontbi have been apont b; Dr. Aitksm in tboroughlj reriiing this Oreal Wort,
and adding to it manj Taluable additions and impraremectc amounting to about 100
{wges of new mntUr, inoludod io whiuh will be found tlie oduption and inaurporiLtion in
the text of the "nea nomenclature of the lioyat Cvltefft of Phjsitiam of London;" to
whicli arn added the Defiiiiliona and the Ftiruigo cquivnlcnta for thMr EngUali nuine*.
The eubjcuts of Malignant Cholera, of Paralyait, of Ej/idemie Cerebro-SpintU jVentw-
fiiit, and of Inteitiiial Oltttniction have been entirolj ro-irrittcn ; and seTsral otlier lub-
j«ct9 in connection vith the trealmont of disease, of the greutut importance, nr« ooo-
•idered for the first time in this edition.
The PreBfl haTB referred to former cditioi
lion." " The must comprehcnsiye of any i
the moat advnnced knowledge of the time."
yet published." " It may be looked opon ai
8 of this work u " an admirablo compilv
I the practice of mediciDe." " It embodiM
" Tbo most valuable cIa«B-bi>ok for fltudanta
the standard text-book in the English Ian-
goage." "The present work cuntaina information that v ill not be Ibund in any uthar
Honual of Modieiuo." to., to.
The ttutlior in thic edition has endonvurod to keep up this high reputation, anil te
■Ake it in every reppccta Ilepraentalive Book of Medical Scienee and the Prad,ioe of Hit
da^i. as understood and followed by the best noa of the Profession.
Large udditionn have iiIhii born mnAv |iy the American Editor, Dr. Msrivitb CbTXU,
vqoal to over 600 pages (if the London edition, nnd with particular reforeuoe to thewanu
■A the Ahrrican PaACTiTioKBK, inehidcd In whiuh are new nrliclM upnn Hie fullowlng
buIijpcIb: Spinal Symploim of Typhoid Feuer. Typlio-Malarial Fever, Chnmic
Camp DyKenlery. Cholera Morbus, Cholera Infantum, Hereditary Syphilid, Gun-
'jrrhoeal Meumaliam, The Delirium of Inanition, Chronic Alcoholism, SyjJnlilK
Diieaxe of thg Liver, EpHnptiform Neuralijia, Capillary tironchUin, Plattic
BronckUiK, Uilalation of the Bronchia, Fibroid Degeneration of the Lung.
Chtvnie Pytemia, Ac. dtc.
Trousseau's Clinical Lectures.
VOL. III. NOW READY.
Lectures on Clinical Medicine^ delivered at the EStel-dieu^ Paris. By
A. Trousseau, Professor of Clinical Medicine in the Faculty of JUedu
cine J Paris t <S:c., iScc,
Trousseau's Lectures on Clinical Medicine, so faTorably received, as well by the
profession of the United States as abroad, are published in this country in cSnnectioii
with the New Sydenham Society, under whose auspices the translation of Vols. II. and
III. have been made. Either of these yolumes can be fiirnished separately, and in order
to still further extend the circulation of so valuable a work, the Publishers have now
reduced the price to Five DoUart per volume.
CoKTBNTS OF VoLUMB I. — TroMlaUd and Edittd by P. Victor Bazirt, M, D., ^c, —
Legturb 1. On Venesection in Cerebral Haemorrhage and Apoplexy. 2. On Apoplec-
tiform Cerebral Congestion, and itb Relations to Epilepsy and Eclampsia. 3. On
Epilepsy. 4. On Epileptiform Neuralgia. 6. On Glosso-laryngeal Paralysis. 6. Pro-
gressive Locomotor Ataxy. 7.. On Aphasia. 8. Progressive Muscular Atrophy. 0.
Facial Paralysis, or Bell's Paralysis. 10. Cross-paralysis, or Alternate Hemiplegia.
11. Infantile Convulsions. 12. Eclampsia of Pregnant and Parturient Women. 18.
On Tetany. 14. On Chorea. 15. Senile Trembling and Paralysis Agitans. 16. Ce-
rebral Fever. 17. On Neuralgia. 18. Cerebral Rheumatism. 19. Exophthalmic
Gottre, or Graves* Disease. 20. Angina Pectoris. 21. Asthma. 22. Hooping Cough.
28. On Hydrophobia.
Contents of Volume II. — Trarulated from the Edifion ^f 1868 {bang the last revised
and enlarged edition), by John Rose Cormacky M. />., Edin.t F.R.S.E ^ ^c. — Lbctubb 1.
Small-pox. 2. Variolous Inoculation. 8. Cow-pox. 4. Chicken-pox. 6. Scarlatina.
6. Measles, and in particular its unfavorable Symptoms and Complications. 7. Rubeola.
8. Erythema Nodosum. 9. Erythema Papulatum. 10. Erysipelas, and in particular
Erysipelas of the Face. 11. Mumps. 12. Urticaria. 18, Zona, or Herpes Zoster.
14- Sudoral Exanthemata. 15. Dothinenteria, or Typhoid Fever. 16. Typhus. 17.
Membranous Sore Throat, and in particular Herpes of the Pharynx. 18. Gangrenous
Sore Throat. 19. Inflammatory Sore Throat. 20. Diphtheria. 21. Thrush.
Contents of Volume III. — Translated from the Edition 0/I868. by John Rose Cormack,
M,D., Edin.f F.R.S E., ifc. — Lecture 22. Specific Element in Disease. 23. Contagion.
24. Oiaona. 25. Stridulous Laryngitis, or False Croup. 26 (Edema of the Lar>iix.
27. Aphonia: Cauterization of the Larynx. 28. Dilatation of the Bronohi and Rron-
ehorrhoea. 29. Hemoptysis. 80. Pulmonary Phthisis. 81. Gangrene of the Lung.
82. Pleurisy: Paracentesis of the Chest. 83. Traumatic Effusion of Blood into the
Pleura: Paracentesis of the Chest. 84. Hydatids of the Lung. 85. Pulmonary
Abscesses and Peripneumonic Vomicoe. 36. Treatment of Pneumonia. 37. Paracen-
tesis of the Pericardium. 88. Organio Affections of the Heart. 62. Alcoholism. 62.
Spermatorrhoea. 03. Nocturnal Incontinence of Urine. 64. Glucosuria: Saccharine
Diabetes. 65. Polydipsia. 67. Vertigo a Stomaoho Lseso.
3 Volomes Ootavo, handsomely boand in Cloth, Price 95 00 each.
OPINIONS OF THE PRESS.
"Trousseau furnishes us with an example of the best kind of Clinical teaching. It is
a book that deserves to be popularized. The translation is perfect." — Medical Times
and Gazette.
**The great reputation of Prof. Trousseau as a practitioner and teacher of Medicine
in aU its branches, renders the present appearance of his Clinioal Lectures pariioularly
welcome.** — Medical Press and Circular.
'•'the publication of Trousseau's Lectures will furnish us with one of the very best
practical treatises on disease as seen at the bedside." — British and Foreign Medico-
Chirurgical Review,
*'A clever translation of Prof. Trousseau's admirable and exhaustive work, the best
book of reference upon the Practice of Medicine." — Indian Medical Gazette.
*'The Lectures of Trousseau, in attractiveness of manner and richness of thoroughly
practical matter, worthily takes a place besid& the classical lectures of Watson and
Graves." — British Medical Journal.
** Trousseau is essentially the French Graves, and his lectures should sooner than
thisiiiave been translated into English."—- Xance^
WORKS BY DR, LIONELS, BEALE, F.R.S,,
Professor vf Physiolo-jg and of General ami Morbid Anatomy in Ki«/»
CoUr.ij'; London, rfc, <<(.'.
FRtCBB REDUCED,
Bcale's How to Work with the Microscope.
Skvkntb Thousand — 400 Ii^ustbationb, some of which ore Colortd,
together wUk a Pkotograpbio FroiUieptect.
Tliia wurk is a cnmplaic mnniinl of mkroMopronl ni«nlpaUtion, and eoalabM • AdI
detcriptian oT iDBa? now pruoeanei or iuve ■ligation, wilh ilirMili'nii fin' •najaiaf
ol^BCU under the liighMt powcn, BniJ fur Ukiiig phutagnph*. Il la go* Bfi. hatt
pUri;« inil leltei^praas, in an cltgnbt manner, and it, iiilhoul donbt. Uia nmi ewfWH
anil beauiirul book of the kind In (bo Sogliih Ungaage,
Octavo, cloth. Price, fl 50
On Kidney Diseases, Urinary Deposits, and
CALCULOUS DISOSDEBH. Including the Symptom*. A<tjr<KMi.
and Trealmejit of Urinary Di»eaara. Wilh full IMrretitfitt for Ote
Chemical and Microncopical Anah/nis of the Vrine tn BeaWt m»i
Dweane. The Third Edition, very niuch enlarged.
This Work is Illustrated with 70 FktM, coDtainiDg apwudi of 400 Mnmt
fignrus, all of whioh have been copied foim Katore, and xaaaj are sow phliihri
for the first time.
A handsume vulume Octavo. Bevelled, cloth. Price, . , (IC W
Tli« compute and iborouglil; p'aelioal oliarnctcr of liiia work naj b* JudcMl «/ kgr
lb* fact tlial il ouiitainB aa man) ,ib ihitiji-ta Jipurrt of differaQt fornta of Um Add
aluoe. — TliB text atid plates linre hasn prinlml on lon«il papi-r, with tba utaioal aan^
lud iliG TTork Is the most complete, as well as the largest, eter puliliahtd on (kt anljact.
Beale on the Microscope in Practical Medicine
FIVE HUNDHBD ILLUSTRATIONS
J7i« Microscope in il» Application to Praitical Medirint. ; by Liokil 8.
BKAI.K, M,B., F.R.S., Ac Tlie Fourti Thousand, thoroughly K«riM<l
by the Author, with nearly 100 pages of New Matter end nutn^-mo
additional Illuatrnliona. In One Volume Oclavo. Price, , $7 M
Bcale's Protoplasm ;
Or. Life, Matter, and Mind. St-eond Edition, muf^h Knlar^J, nA
Hitjhl Colored lUuttralionit ; and an tntirrly new trction on Jli»d
By LiONiL S. Bbalk, M.B.. F.R.S , and AuUior of "Hovi to Work At
Micrugvope," "The Microscope in Practical Mvdicine," ^.. iv. Ii
One Volume, Price, |3 Uf
Beale on Disease Germs,
J'ficir jSuppoied Nnlure, Wtik CoU)T«.i Pl<ti<it, uniform wiih " PEnn
I'l-AKM." In One \ oVame \^m«, Ci\q\^. "S-p.**. . \\^
Althaus's Medical Electricity.
A NEW AND VSRY MUCH ^NIiARaBD EDITION.
A Treatise on Medical Electricity ^ Theoretical and Practical f and tit
Use in the Treatment of Paralysis, Neuralgia^ and other Diseases.
The Second Edition, revised, and for the most part re-written. By
Julius Althaus, M.D., Member of the Royal College of Physicians,
Senior Phytiician to the Infirmary for Epilepsy and Paralysis, Ac., ike.
In one volume, octavo. Illustrated by a Lithographic Plate and sixty-
two Engravings on Wood. Price, $5 00
It is with great pleasure that we welcome, and cordially recommend, Dr. Althaus's
treatise, in the improved guise of a Second Edition. Dr. Althaus's work possesses the
merit of being clearly and agreeably written, while its teaching is in accord with the
most recent information ; and the balance is evenly held between the relative virtues
of galvanization and faradization — a point of the highest importance in the treatment
of ditiease.
To the favorable opinions already accorded to the former edition of this treatise we
can add nothing, except in the way of sincere commendation; and to Dr. Althaus belongs
the credit of having filled up a hiatus in English medical literature, by the production
of a sound, comprehensive, and practical work on the right use of an agent whose
powers are daily becoming better recognized and more clearly defined. — Dublin Quar-
ttrly. May, 1870.
Tyson's Work on the Cell Doctrine.
The Cell Doctrine: its History and Present Stale. With a Copious Bib-
liography of the Subject. For the Use of Students of Medicine and
Dental Surgery. By James Tyson, M.L)., Lecturer on Microscopy in
the University of Pennsylvania, and on Physiology in the Pennsylvania
College of Dental Surgery ; Fellow of the College of Physicians of
Philadelphia, &c., &c. In one volume, with a Colored Plate, and
numerous illustrations on Wood. Price, . . . $2 00
•
Dr. Tyson furnishes in this work a concise and instructive rttumi of the origin and
advance of the doctrine of Cvll evolution. In it we find the theories of Virchow^ Robin,
Huxley, Hughes, Bennett, Beale, and other distinguished men. Its pages contain what
could otherwine only be learned by the perusal of many works, and supplies the reader
with a continuous, complete, and general knowledge of the history, progress, and
peculiar phases of the Cell Doctrine, accompanied by careful references and a copioas
bibliography.
Legg on Urine, from the second london edition.
A Guide to the Examination of the Urine. For the Practitioner and
Student By J. Wickham Lego, M.D., Member of the Royal College
of Physicians, dec. J <tc. Second Edition. * 16mo. Cloth. Price, 15 cts.
Dr. Legg^s little manual has met with remarkable success, and the speedy exhaustion
of the first edition has enabled the author to make certain emendations which have
added greatly to its value. We can now confidently commend it to the student as a
safe and reliable guide to such examinations of the urine as he may be called upon to
make. — London Medical Times and Gazette.
Kirkes' Hand-Book of Physiology.
THE SEVENTH LONDON EDITION.
HAND-BOOK OF PHYSIOLOGY, by William Senhouse Kirkm,
M.D. Seventh Edition, Eldited by W. Morrant Baker, F.R.C.S., Leo
turer on Physiology, (fee., dec. With 241 Illustrations. In one volume,
demy-octavo, containing over 800 pages. Price, bound in cloth, $5 00
This edition of Dr. Kirkcs' Hand-Book of Physiology is fully brought up to the times,
and forms one of the most complete and convenient Text-Books on the sulgect, for <'
Student of Medicine, now in print.
J. Sa'lberg Wells on llie Eye.
A NEW ENLARGED LONDON EDITION.
J TrcaHni: m Disrate.'' of Ihc Eye (Ibe Ai-thor/, S-vord Editif,n),ihm. ,
Iralfd by Colored Plat's and iiumi^ruvs Engratyiuga on Wuod. By
J. StELnEKa Wbi.LS. Pro/tumir of Oplilhalm'-liuj>i in JCing^n Cullri/t,
London, ifc,, <£o. Tliu plates aod lellcr-presa elegantly pHmod on
creaiu-linted paper. Octnvo, bound iu Cloth. Price, . . 8B fiO
Do. " Leather, " . . T 50
THE ADTHOK'a FRBFAOB TO HIS SEOOUD ESmQB.
It huB afforded me no ainiill grntincaiinn thnl tlie Firai Edilioii of lliis ivark mIiouM
htivv met Willi 80 TriMPftble n r*ccpliiin, Ijolh by ihe Profi-SBiim Bt Urge «liJ hy iht
llritmh and Foreign Meiliriil PresB. itnil ^"pefiiallj Miiil il b'hiiiIiI Uatv been ilrfmrJ
vrortliy or being trAnBlnlud into FrencU «iiil tierunn, in baili ol which liiDgDiig«« it will
be giublUliod iu Ibe oourse of this fear,
Siiimilnted by siieh eneourngeincnt. I linve iMideArgrod 'o render the Second E<liii«ii
>s ccmplote ai pnasihle, sn'l hairc lunilu uiimerouH ailditionK. IncorporaiiDg alt tb«
important fids elilcidHlrd by ibe mnnt rccenL maenrefatrs, «d iIiai iba work mtglil bg
brought up 10 Ihn laleaL dale.— tQ Savitlr Raa, I.ouJon, May.' 1870.
Coles on Defornutios of the Month.
SECOND EDITION. NOW BEADT.
On Di-formilies of the MovJh/Cong-Mnlal and A'-qairnd. with Ihrir
Mf.chanical TrealmenL By James Oaki.EY Colks, tfenliat to Ihe
Banpilal for Dineanea of th« Thmal. Member of the Odonfolfyiral
Society, £0., dx. Sci-'ond Edition, Revised nnd Enlarged,- coutaiuiag
Eiu^it Colored Pliiteit ami Fifty-one Enffraiitiffs on H'ootl.
Ono Volume. Demy-Octavo, in Oloth. Price, , . , 82 5 (J
Ol'ISIONS OF THE PRESS ON FIRST EDITION.
"This worli is full at useful iufortnutioo, Tlie records of crises troU«d *i« noil
eD«.,iii-aging."— /.<!«"(.
-Tl.la boaulifuUy illuWraterl work denN with a highly praciionl and interMlini
■ubjool."— JftdifoJ Tfiari and Uat'tlt.
'• We take plenaura in conimsniliag il ag a tnlunble. and tbL-retort deeirnblo, treatise
1ft poBBeas." — J>enlal Clumitt.
NeuMiaun's Iland-Book of Skin Diseases.
Translated iroin the Antiut's Second Edition. IS PEEPAEATION.
A Band-Book of Skin DiKraaeg, ittmtToifd hi/ Foj-lij-ninf Wood Cult
of lanji- siiit, beautifully exKruled, and ehowimj Ihe Mi'^fMeupic Ap-
pearance of Seeliong of the Skin in iU Fariouu Diteaneis. By PaoT.
Neumann, of Tion
Dr, Nru
IX 1l>tl
In one Tolui
o Pri.f, HmI)
'a rmfifliant, anil his work ia ■ eoaclaa
tros'iM raiinded nn -I[«l>ra'8" Drrictrinea and Miiihudaof TrSBtncnl, a* thvlallvrworl
way n'li for i> long ilmi; be oomiiUicd, aud a« fruiu ila aiio and i1» publioarion Id Iha
Eiiftiih Inntiinpe niilj hy ihe New Sj-di't.bani Sooieij. il, oH.ii.ol, even wh«n*JI pulOlabnl.
bi n'-crs*iM>biil to n ilinitod number. This wark^rusetitiugbiBiietm, miini nnitnnMrilj
<'««^ graai i.c(iufiilioii to lilt pTutsaaiiiu. j> v. ' ' ' ■ —
LINDSAY & BLAKISTON'S
MEDICAL PUBLICATIONS.
''The Representative Book of Medical Science." — London Lancet.
Aitken's Science and Practice of Medicine,
SECOND AMERIOAK from the PIFTH LONDON EDITION.
In 2 Volumes, containing 2000 Royal Octavo Pages, a COLORED MAP, a LITHOGRA-
PHIC PLATE, and ONE HUNDRED AND THIRTY ILLUSTRATIONS ON WOOD.
Price, bound iu Cloth, bevelled boards . . . . $12.00
" Leather . U v'O
Dr. Aitkvn*8 work is now the most comprehensive Text-Book on the Practice of
Medicine in the English Language; the present edition has been enlarged and care-
fully ri'vised by thu author, as well as by the American editor, Mbriditii Clyner, M.D.,
the lutier having made additions of original matter equal to nearly 500 pages of the
English Edition, with special reference to the wants of the American Practitioner.
Acton on the Fnnctionsand Disorders of the
productive Orirans.
IleiJ
o
Second A Jtierican from ilie Fourth Jjondon EdvLiotu OarefuUy revised by
the author^ with additiwis. Just Ivcudy, octavo, . . . $3.00
''Wo think Mr. Artnti hiM <lori^ gnod nrrrice to itcMy hy ftnippliiig manfully with Mxnal t1c«, and w«
tniMt that iithcrB, whcitM' |NM4itioit mj« ni»ti of arienr^ nu<1 tMiclieri* «iuil<l«> tlieu to t|t«ik with aatbodty, will
■Mint io roDiliMtiriK Hnd arrf«riiif{ thf ^tIIn wbirh U eiitailrt. W» ar* of the opinion that the tplrit whieh
pArvailifi it is ouf tliMt iUu-n cnilit equniljr to the head and to the heart of the aathor.**— TA* ^ntfiA i
• •
Anstic on Stimulants and Narcotics.
Tlieir Mutual Relationn^ with Special Reeeardies on the Action of Alcohol^
Ether, and Chlorojonn on the Vital Organism* *By Francis E. Anbtie,
W.l)., AssUtant Physician to Westminster Hospital, Lecturer on Materia
Mediea and Therapeutics, etc., etc. Octavo, . . . . $3.00
Altliaus' Medical Electricity, a New and very muck
Enlarged Edition.
A Theoretical and Practical Treatise, and its Use in the Treatment of
Parnlyaii^, NeuraUjia^ and other Diseases. By Julius Althaus,
M. D., Member of the Royal College of Physicians, dec. Second
Edition, revised, enlarged, and for the most part rewritten. In One
Volume Octavo, with a Lithographic Plate and nixty-two Illustrationa
an Wood Price, $5.00
LINDSAY AND BLAKISTON'S PUBLICAIIONS.
PEOF. BYTORD'S NEW EDITION
OF
,T.he -Practice of Medicine and Surgery,
Applied to the Diseases and Accidents Incident to Women. By W. EL
Byford, a. M., M. D., Professor of Obstetrics and Diseases of Women
and Children in the Chicago Medical College ^ &*., dec. The Second
Edition f revised and enlarged, with additional illustrations, Oiv»
volume octavo.
Bound in Cloth. Price, .... . $5.00
" Leather, 6.00
The rapid sale of the first edition of this book,. which was exhausted in a little mors
than a year, has enabled the author to carefully revise the whole work, add manj
improvements, and to make a large addition of new matter, without, however, materi&llj
mereasing the size of the volume.
" Professor Bjford's book may safely be said to fill a gap in a most important department of
tfao bcaling art. The treatise is as complete a one as the preticnt state orour soiAnce will admil
</f being wrtttun, and not ouly gives us the cases in which the kuife is to be called into requisi-
tion, but fully discusses all those uterine ailments which are to be benefited by medical treat-
ment. In this latter respect, the work has a peculiar value to €f^cry general practitioner. The
author speaks from experience, evidently with the sole object of presenting bis subject in a
strictly impartial and scientific lighL The present edition it* much enlarged in point of matter
eontained in the work, although the volume itself is very little, if any, increased in bulk. We
commend it to the diligent study of every practitioner and student, as a work calculated to
inculcate sound principles, and lead to enlightened practice." — A'. Y, Med, Htcord,
''This work treats well-nigh all the diseases incident to women, diseases and accidents of
the vulva and perineum, stone in the bladder, inflammation of the vagina, menstruation and
its disorders, the uterus and its ailments, ovarian tumors, diseases of the mamma;, puerperal
convulsions, phlegmasia alba dolens, puerperal fever, Ac. Its scope is thus of the most
extended character, yet the observations are concise, but convey much practical information."—
London Lancet,
BYFORD ON THE UTERUS.— PREPARING. .
A Xeir, Knhirgcd, and Illustrated Edition.
On the Chronic Inflammation and Displace-
ments of tlie Unimpregnatcd Uterus,
A New, Enlarged, and Thorougbly Revised Edition, with Illustrationa.
One A^'olmne. Octavo.
Biddle'S Materia ]\[ediCa. The Third Edition Enlarged.
For the U-^e of Students, A Nerv Enlarged Edition. WUh IllmtratU)n$,
By J. B. BiDDLE, M. D., Professor of Materia Medica and Therapeutic
in the Jefferson Medical College^ Philadelphia, etc., Ac, Octavo. $4.00
This is a thoroughly revised and enlarged edition of Prof. Biddle's work on Materia
Medica. It is designed to present the leading facts and principles usually comprised
under this head, as set forth by the standard authorities, and to fill a vacuum which
seems to exist in the want of an elementary work on the subject. The larger works
nsually recommended as Text-Books in our Medical Schools are too voluminous for
convenient use. This work will be found to contain, in a condensed form, all that is
most valuable, and will supply students with a reliable guide to the couraee of lecture!
IB MAteria Medica, as dcliTercd at the variouB Medical Schools in the United Sutei
LIND8AT AMD BLAKISTON'S PUBLICATIONS.
Beasley's Book of Prescriptions.
I
A NEW) KEVISED, AND ENLARGED EDITION.
QnUaining 8000 Preacriptiona, col^eUd from the Pradice of the mod.
Eminent Phyaieians and SurgeoM — English, French, and American:
eomprising also a Cknnpendious Hiitory of tJie Materia Uedica, Lists of
the Doses of all Officinal and Establislied Preparations, arui an Index of
Diseases and their Remedies. By Henby Beaslet. Second American
from the last London Edition, Octavo. .... $4.00
** Tba kUtor, eareftally lelectiDg fh>m tb« imm of matflrials at bis dlflpoaal, htm eoaiiia«d * Tolumtt, in wUoh
koth phyticiaa and drnggiat, presoriber and oompoander, may flod, aod«r the head of each remody, tha maii-
nor Id which that remedy may be mott effectively admini«tered, or combined with other medicines in the
treatment of Tarioos diseaaea. The alphabetical arraQgemeot adopted rffiders thla easy ; and the valne of the
Tolame ia itill fiirther enhanced by the ihort account given of each medicine, and the lists of doses of Its
sereral preparations. It is really a most nseftil and important publication, and, fttmi the great aid which it
is capable of affording in p^'escrtbing, should be in the possession of erery medical practttioner. Amongst
ether advantages i«, that, by giving the prescriptions of some of the most able and snccessfhl pra^titionaa of
the day, it affords an insight into the methods of treatment pnrsned by them, and of the remedies which tbey
ehiefly employed in the treatment of different diseases." — Laned,
Beasley's Druggists' General Receipt Book.
SIXTH AMERICAN EDITION, REVISED AND IMPROVED.
Comprising a copious Veterinary Formulary, numerous Receipts of Patent
and Proprietary Medicines, Druggists^ Nostrums, etc.; Perfumery and
Cosmetics, Beverages, Dietetic Articles and Condiments, Trade Chemicals,
Scientific Processes, and an Appendix of Useful Tables, by Henry
Beasley, Author of the Book of Prescriptions, etc, etc Sixth American
from the Last London Edition. Octavo. . . . . $3.50
"This is one of the clsss of books that is indispensable to. every Drngght and Pharmaceotist at a bodk of
reference for snch information as is wanted, not oontnhied in works used In the regular line of his busiBes^
and we can recommend it as one of the best of the kind.**— ^mmcon DruggiM drcidar,
Barth & Roger's Manual of Auscultation and
Percussion.
A new American Translation from the Sixth French Edition. 16mo. $1.25.
"This is one of the most osefhl and practical manuals of Its sort that has ever yet appeared, and we can*
■ot too strongly recommend it to every student of medicine. It is sufficiently compreheiudve without being
lengthy, and (he prfndplfla, wfaloh are eminently sound, can easily be mastered and nndsntood."— if<d<oai
Beeord.
Bouchardat's Annual Abstract
Op Therapeutics, Materia Medica, Pharmacy, and Toxicology,
FOR 1861, with an Original Memoir of Oout, Qravel, Urinary Cal-
culi, &c. By A. Boucuardat, Professor of Hygiene to the Faculty
of Medicine, Paris, dec. Translated and Edited by M. J. De Rosset.
M.D., Adjunct to the Professor of Chemistry in the University of
Maryland. In one Volume. Price, in cloth, . . $1.50.
I
'lIKDSAV A»D BI.AKTflTOK'8 PtWLlOATKMIfc
Atidrcws' HiiiiJ-BooU of ilio Practice pj
Medicine, in preparation.
Bull on the Maternak Management of Chil-
dren in llcalth and Disease.
A New and Improivd Edilia-i. B/ Thomas Bcll.M.D., Metubrro/Ut
Royal College of Phyxieiana. l2mo tl-ti
Reports on the Progress of Medicine, Surgery,
and the Allied Sciences, comaining:
1, Rki-oht ov FiirtioLMT, b; Hanrir Power, V.H.C.S., M.B., Laail.
%. KiruHT ON PiMunoii. UKi»ot*>, bj Fnuioti Bdmund Antti*, U.'D., aMk
3. KifMiT ON StTNsaHr, by T. H»lm«t, E>q„ M.A^ F.R.C.S., eu.
4. Rki'oiit 01 Or-aTD^i.uic MBOiriiiR iim SunaiiiT, Ljr TbouM WiobM, ILD.
b. REronr OH MiDWiriHT ino tdk Disrxus or Wohbk asp CuiuiBKa, by K. Bit»^
U.D., F.HX-P.
5. KxroiiT ret HniiCAL JcMiHPitviiii'ca, by C. Hilton Fkgfe, MJ>.. P.R.O.P.
T. RCI1>RT OK MATHtU MlDICA AKD UuiDAI. TBIBAPIDTm, by C- ItilLsB P^C% ILBl*
?,B.C.P.
a. RiroRT OS PuiLio IIiiLTii, bj C, niUon P>K(e, U.D., (to.
In One Yolume, hEindsoracIj bound id cloth, Price, . . t^ H
•equlii'Kl. Nuzh dipirlnunl l> In ebiir|( at ■ (sbiIhijui ot r.puuilun, uii nrrjAlaf U *^ t> »m,
mrtln. <n • torr riwliil:l> wnjr. oil <b> UDr* Imponul idiuea* of biiIMIim xw lk« fbtt*. U li kaiA
Birch on Constipation. From th« uird Louduo Ediuo^
• CONSTIPATED BOWELS: the variout Cauxta and thr Ihfrrrxi
J/.'UFi0 •/ Cur«. By S. U. liiKCK, M. D., Jtember of tfi< Rt-/al CVJcyi
of Phi/Kician» of London, dv. The Third Edition. One rolutu*, !«»*
Pri'iw, ■ ll.Ot
Braitliwaite's Epitome of the Retrospect of
Practical Jlcdicine and Surgery.
Two likrgu OctiLvo Voluuies of DOO pages each, . . . |IJ4I«
Braithwaite's Retrospect of Practical Medi-
cine and Surgery.
" Tbe omtn of mnlieiil ■lierAiuTi."
Pvhluhrd hoJJ-yearly, m Jarwary and Jtdy, at »i50 fttf bammm, ifpmid m
ot/ranee; ot- 81.60 /or *in;^f.(irU.
IiINDBAT AND BLAKISTON'B PUBLICATIONS.
British and Foreign Medico-Cliirurgical Re-
view, and Quarterly Journal of Practical
Medicine and Surgery.
Publusfied in Landort on Uie 1st of Jamtaryf April, July, and October, ca
6 shUlingB per number, or 24 shillings per annum, and furnished in this
country ai 810.00 per annum ; being much less tlian the present cost of
importation of English books. Containing Analytical and Critical Re*
views, a Bibliographical Record, Original Comviunic€Uions,anda Chron-
icle of Medical Scieiice, chiefly Foreign and Contemporary.
This is considered the leading Medical Review in the English language. It is every-
where looked upon as high authority. It presents in its pages a large amount of valu-
able and interesting matter, an<i will post the physician who reads it, fully up to ih«
present day in medioal literature.
Chambers's Lectures on the Renewal of Life.
A New American from the Fourth London Edition.
Lectures chiefly clinical, illustrative of a Restorative System of Medicine.
Bj Taoa K. Ouambeus, M. D., Physician to St. Mary^s HosjAlaL
Author of " The Indigestions," &c., <fec. Octavo, . . $5.00
" The medical profeMlon in this country are under ohligntioD* to the American publivberi
for this reprint or Dr. Cbaubers' Lcoturea — a work whose time is forevor, everywhere in its
place, admirable in tone, full of valuable instructions and practical teachings, and written in
elear, compact, and often epigrammatic Kugiish. We can oner but a brief notioe of this intrin-
sicallj good book, which is certain of finding a wi«le circle uf readers, and wo should hope a
place in every medioal library." — New York Medical Journal.
"This work is of the higliest merit, written in a clear, masterly style, and devoid of technicalities. It is
■imply what it prorntisos to be, Lectured Clinical, deliver4<d fmm castw obnenrcxl at the bfxlMide; therefore
nif»m valuable an enuuciating the vifws luid exp^rieucMi of a practical aiiud aided by actual olHUTvaliun.
They are of deop lotereHt, and rvploto with Tactti having a practical l*oaring. ami will well repay periiiuil
We can rncommenil Dr. ChumtN;rfl' hook frof^I j and with confldcnco, an the work of a great mind practical !■
Its bearing, and simple to the understaodlog of nlL"^ Canada Mediad JoumaL
Chew on Medical Education.
A Course of Lectures on the Proper Method of Studying Medicine, Bj
Samuel Chew, M.D., Professor of the Practice and Principles of
Medicine and of Clinical Medicine in the University of Maryland.
12mo . . «1.00
"The topics discussed In this volume are of books— of time to lie devoted to study —and the manner — of
tbeonler of nitHllcal studies— of the taking of notes — of clinical iuetructiou — dissections — auscultation-^
modical scIiooIn, Ac.
** Dr. Chew wan an emineot member of the medical profHMion, and a well-Known teacher of me^llcint*. lie
was, there/ure, well tttted for the Judicious p«rfurniauc« of this taak, upon which he seems tu have mtorrd
with Interest and pIcHaure. It is a well-timed UH>k, and will N«rT« aM a numt vxcellent mauual tor thcsiuUfi^
■a wall as a refreehiug and suggestive one to the practitioner.^ — Lancet and Ohmroet.
LINDSAY AND BLAKISTON'S PUBLICATIONS.
Cazeaux's Great Work on Obstetrics.
The Fifth American Edition. 175 Illuatrations.
A Theoretical and Practical Treatise on Midwifery. Including the Di§'
eases of Pregnancy and Parturition, and the attention required by tht
Child from its Birth to the Period of Weaning. By T. Cazeaux,
Member of the Imperial Academy of Medicine, Adjunct Professor in
the Faculty of Medicine of Paris, (fee, &c. Revit^ed and annniaied
by S. Tarnier, Adjunct Professor to the Faculty of Medicine, Parig,
&c., &c. Translated by W. R. Bullock, M. L). With new LHhh
graphic and other Illustrations on Wood, One volume Royal Octavo,
of over 1100 pages.
Price, bouud in Cloth, Bevelled Boards, .... $G.50
" " Leather, 7.60
** Written expresdly for the ntie of Ktuflootn or niedicioa, and those of midwifery wp^cially, itfl tnurhinp art
pUio and explicit, presenting a condendod 8timmury of the leading principles esttiblifibed bj the masters of
ic* obstotric art, and such clear, practical directions for the nianagi^nient nf the pi^'gnant. pai hirieut, sai
(Nieineral statetf, as have been sanctioiiiHl l)y the niotit authoritative i>ractitiunera, aud confirmed bj tbt
author B own experience. Collecting hiH nmteriala fntin the writings of tlie entire bo<iy uf autece<lent vritcn,
carefully testing thvir correctness and vuliie by hiH own daily experien^ and rejecting all nich an wers tM-
fled by the namerous caetes brought under his own iuimiHliate obserTation, he haif formed out (tf them a body
of doctrine, aud a system of practical rules, which he illustrates and enforces io the clearest and most simplt
maimer possible." — lisamiiKr.
Canniff 's Manual of the Principles of Surgery.
Based on Pathology, for Students, by Wm. Canniff, Licentiate of the
Medical Board of Upper Canada; M,D, of the University of Nev
York ; M,R, C,S, of England ; formerly House Surgeon to the Seamen't
Hospital, New York; late Professor of General Pathology and the
Principles and Practice of Surgery, University Victoriu College, C, W.
Octavo $4.50
•'Thi<« manual is evident' y the production of a man who in wi-ll infurm^'J oti his (•ubject. an»l w\u^ n!"r*^'Tei
has hn«l cxporicnco ns a tioicher and a-* a pr«rtiti.*iH-r. H«« has pn>rito«l liv tin* (*tn«ly <»f th»' \>rvt anthorv i*
the prin«"i|»:<^ of surgery, twted pnictinill)- tlu-ir (lootrinen, and ban prf*ent«»J \\\i* owtj views, well arranged
and ck'Hi iy exprosne*!, for the advantage of others." — American Journal of Med. Scienct,
Clcavcland's Pronouncing Medical Lexicon.
A NEW AND IMPROVED EDITION (THE EliEVENTH).
Containing ilie Correct Pronunciation and Definition of most of the Tenn$
iu<ed by Speakers and Writers of Medicine and the Collateral Sciences.
By C. n. ClKcVVELand, M.D., Member of the American Medical A.'fsc^in'
tion, etc., etc. A small Pocket Volume $1.2.*)
Tbis little work is both brief and comprehensive; it is not only a Lexicon of all the
^ord8 in common use in Medicine, but it is also a Pronouncing Dictionary, a feature
of great value to Medical Students. To the Dispenser it will prove an excellent aid,
and also to the rharmaceutical Student. This edition contains a List of the Abbrevia-
tions used in Prescriptions, together with their meaning; and also of Poisons and their
Antidotes: two valuable additions. It has received strong commendation both from tht
*4ieal PreM and from the profession.
LINDSAY AND BLAKISTON'S PUBLICATIONS.
Cohen on Inhalation.
lis Therapeutics and Practice, A Treatise on the Inhalation of Oases,
Vapors, Nebulized Fluids, and Powders; including a Description of
the Ajyparatus eviployed, and a Record of Numerous Experiments,
Physiological and Pathological ; wUh Cases and Illustrations. Wy I.
SoLis Cohen, M.D. 12iuo. Price, $2 50
** We recoguize in this bo<'k the work of a persevering Physician who has faithfully
studied his subject, and added to its literature much that is useful from his own expe-
rience. It treats respectively of the inhahitiuns of nebulized fluids; of medicated airs,
gases, and ;apors, and of powders. Dr. Cohen has given us briefly and clearly what-
ever is vuluuble in relation to the insutllation of powders in respiratory affections, with
the experimental proofs and pathological evidence of their penetration into the bron-
chial tubes and lung tissues." — American Journal of Jledtcal Science, July, 18G8.
Prof. Carson's University of Pennsylvania.
A History of the Medical Department of the University of Pennsylvania,
from its Foundation in 1705: With Sketches of the Lives of Deceased
Profesmrs. By Joseph Carson, M.D , Prof essor of Materia Medica
and Pharmacy in the University of Penmiylvania; Member of the
American Philosophical Society , etc. In one volume octavo. Cloth.
X rice, •.•**•«•.•. v** 'HI
**The history of the University of Pennsylvania has a national as well as a locat
interest, from the early date of its origination, and the connection witli it of men of
illustrious public reputation, such as Drs. Franklin, llush, Physick, Gibson, Dewees,
Chapman, Wood, &c., &c.
** For fidelity and carefulness of statement and maintenance of the dignity of the
Institution, as well as for skill in literary execution, the task of extending and con*
tinuing this record cuuld have been confided to no better hands than those of Professor
Carson.
*'For the labor and love which he has spent in preparing this most interesting and
Taluahle work. Prof. Carson bas earned the gratitude of the alumni of the University,
and of all others interested in medical education in this country." — American Journal
of Medical Science.
Dixon on the Eye. } ^^- JS^'Ee-ZS ^''^' "•' '
A Guide to the Practical Study of Diseases of the Eye, with an Outline
of their Medical and Operative Treatment, with Test Types and Illus-
trations. By James Dixon, F.R C.S., Surgeon to the Royal London
Ophthalmic Hospital, &c., &c. In one volume. Price, . $2 50
"Mr. Dixon'H book is essentially a practical one, wl-iiten by an observant author,
who brings to his special subject a sound knowledge of general Medicine and Surgery."
^^ Dublin Quarterly.
*' Our object is not to review, but to recommend this work to students, with the confi-
dent assurance that they will rarely be disappointed in their appeals to it as a reliabte
guide to the practical study of the Diseases of the Eye." — American Medical Journal.
*» We have taken great pleasure in a lareful perusal of this book, which, both in styre
»nd matter, is unsurpassea in any language It embraces quite a wide runge of topics,
and furnishes a very valuable practical guide in the medical and surgical treatment
of diseases of the eye.'' — Buffalo Medical Journal.
LINDSAY AND BLAKISTON*S PUBLICATIONS.
Durkee on Gonorrhoea and Syphilis.
The Fifth Edition, Hevised and Enlarged, with Portraits and Colored
Illustrations.
A Treatise on Gonorrhcra and Stjplnlis, By Silas Durkek, ^I.D., Fd-
low of the Masmchu^etts Medical Society ^ d'C, d'c. A Neiv and Jievued
EditioUj with Eight Colored Illugtrations* Octavo. . . $5.00
This work of Dr. Dukkek's has rcooivwl the unqiialifie<1 approval
of the Medical Press and the Profession both in this country and in
Europe. The author has <lovoted himself especially to the treatment of
this chiss of diseases, and his 25 or 30 years experience in doing so is
here rewjrded. No one reading his work can fail in receiving very
valuable information from it.
" It \» tho work of a practical man, the enbject is treated in a plain, shrewd manner. Tho
book \9 a i^ontl one, and the therapeutics are laid down with discrimination." — London Mttiiml
Timen and Oattttt,
**Dr. Ihirkfv'i prodnctlon Is one of thoMs the pemsal of which impretwes the reailcr In faror of the nothor.
The gPiKTiil toiif. (hi> fhortiii^li honpntj e>vprywliffrt4 eviiir«'i|. the phnniithrop!? spirit olniorTaMe In oianjr y*^
saffen, nntl the enfrp^tic atlvttcary of pn.ife««ionMl rertltiuie, vi)eak liighly of th^ niontf ezrvllence of the
writto", nor i* the rciiil«T leM iittmcte<I by tlie skill with which the book is armncM, the manner in which
th^ factfl are ritt-d, the clover why in whirh th« author's ex|M>rl«*nce i^ hmn^ht in, and the luoiditr of the
reasoning, the fre«]U<'nt and extirmHy fur allusions to the laboiv of others, and the care with wliich the ths-
Mpentlcs of Tenereal compUints are treated." — LanotL
Fuller on Rlieumatism, Rheumatic Gout, and
Sciatica, a new edition preparing.
Their Pathology, Symptoms, and Treatment. By Henry William
Fuller, M.l)., Fellow of the lloyal College of Physicians, London;
Physician to St, Georges Hospital, etc. From the last London Edition
Octavo.
Graves' Clinical Lectures on the Practice of
]\[e(licine. By UoBEar James Graves, M.D., F.R.S., PrnjW.^nr
of the Insfifutes of Medicine in the Sehool of Physic in Ireland. Edited
by J. Moore Meligan. M.D. From the Second Hevised and Enlnrgfd
Edition. Coiiiplcte in One Volume. Octavo. Price, . . I'l.OO
Goff 's Combined Day-Book, Ledger, and nmh
Rerjialer of Patients, romhininy not only the Acc'/rary and Essrnfffil
Points of a regular Lny-Book and Ledger System, wifhont any of the
labor find responsibility, but is also a Daily Register of Patients, dr., (f-e.
A large Quarto Volume, strongly bound in half-rnssia. Price, ^* 12.00
The julviintAK^'S of thiB book nru — Tlie account of a ichoU family for an nitirr y/r can
be kept in a very sniall space. (See Mitchell's Jiccount.) No tran-fer of m-munti
from one book to another, or from one part of the book to another. No protracted
search for an account when wanted, fihows the exact state of an account ai anj
momoDL
LINDSAY AND BLAKISTON'8 PUBLICATIONS.
Gross' American Medical Biography of the
Nineteenth Century.
Edited by Samuel D. Gross, M.D., Professor of Surgery in the Jefferson
Medical College^ Philadelphia^ etc., &e. With a Portrait of Benjamin
Rusu, M.D. Octavo $3.50
GreenhoW on Bronchitis, especially as connected vnth
Oout, Emphysema, and Diseases of the Heart. By E. Headlam Green
HOW, M.D., Fellow of the Hoyal College of Physicians ^ d^c.^ d:c.
Price, $2.00
" Id viTid pirtiirM of the imrt of cases whirh a pmrtitioner •ncnnntcrs in his dally walks, and in fxaniplM
cf tli<> WRj In which a stiidetit oii^ht to tnrn th(»m over in hin mind ami make them tools fur self-Impror*.
Bient, we hare rarely seen a Tolume richer." >- BrU. utid For. Mediw-Cftirurg. Rtview,
Garratt's (Alfred C.) Guide for Using Medical
Batteries.
Slwwing the most approved Apparatus^ Methods, and Pules for the Medical
Employment of Electricity in the Treatment of Ncn'ous Diseases, d'c,^ d:e.
With numerous Illustrations, One Volume, octavo. . . $2.00
** The lar^p work on the snnie Kabjvct, iin'l hy the Rflra«> antlior, is pretty Wfll known to the ProfeMdon. but
It is bulky Hud cnmbrouH, und l>y no nioitns »<> i>nu'tiriilly UK'riil. The proi«>nt coniimratively briff Tolnms
UNitainH every thin^ "f iui|>ortHnco in reg-.ird fo the vuriiMH appaniturien UHeful to the Uedical Electrician
MmI the varluus uiudvs of applicuUuu fui therupeutic purposes." — Lancet and Observer.
Hewitt on the Diseases of Women.
SECOND EDITION, REWRITTEN AND ENLARGED
The Diagnosis and Treatment of Diseases of Women, including the
J)iaynosis of Pregnancy. Founded on a Course of Lectures delivered
at St. Mary's Hospital Medical School. By Graily Hewitt, M. D.
Loud., M. 11. C. P., Physician to Ute British Lying-in Hospital; Lec-
turer on Midwifery and Diseases of Women ami Children at Si. Marjfs
Hospital Medical ^School: Honorary Serre/ary to the Obstetrical So-
ciety of London, Ac. With a new Series of Illustrations,
Price, in cloth, $5.00; in leather, $G.OO.
HHlier's Clinical Treatise on the Diseases of
V-zlllidren. By Thomas IIillier, M.P., Physician to the Hospital
for Sick Children, and to University College Hospital, dec, &c. Octavo.
Price, $3.00
**Oiir MiMtre is exhauittefl, but we have said enough to Indicate and llhistrate the exeollence of Pr. IIIDier's
Toluaie. It in omineiitiy the kind of l)ook needed by all medical men who wish tocnltlTate cIlDital aorvacy
aad sound practice." — Undtm LanoeL
X-INDSAY AND BLAEISTON'S PUBLIOATIOKB.
Headland on the Action of Medicines in the
System.
By F. W. Headland, M.D., Fellow of the Boyal ColUge of Pliynieiant
(tc, &c. Sixth American from the Fourth London Hdition, Revised
and enlarged. One Volume, octavo $3.00
Dr. IIcadland*s worlr has been out of print in this country nearly two jeans, aw^U-
Ing the reviKions of the author, which now appear in this edition. It give? the oul)
scientific and satisfactory ticw of the action of medicine; and this not in the way mI
ifUo speculation, but by dcmouslration and experiments, and inferences almost as in-
disputable as demonstrations. It is truly a great scientific work in a small compassi
and deserves to be the handbook of every lover of the Profession. It has received the
most unqualified approbation of the Mfdical PrefSt both in this country and in Europe,
and is pronounced by them to bo the most original and practically useful work that has
been published for many years.
Hille's Pocket Anatomist.
Being a Complete Description of the Anatomy of the Human Body ; /or the
Use of Students, By M. W. IIilles, formerly Lecturer on Anatomy and
Physiology at the Westminster llospital School of Medicine.
Price, in clotli 81.00
'' in Pocket-book form, 1.25
Heath on the Injuries and Diseases of tlie Jaws.
TItt' Jark'ion tail Prizp Eiisat/ of the RoiinJ Collrne of Surr/fons of Ean-
land, iSfiT. By Oiiiustopiier Hp:ATn. F.R.C S., As:<i.<fanl Surifrn') to
UnirrrsHi/ CoUrcjt*. Hospital, and Trarher of Operative Surgi^nj in f'ni'
veraifi/ College. Containinfj over \hO IlluMratiom^. Octuvo. Prirc. ^'j.oC
IIo(l«;e on Fa3ticide, or Criminal Al)or(ioii
Bv JlrcHi L. HoDOE, M. I)., Emeri'ns Professor in the Univ- rsif.i nf
Pennsylvania. A Small Pocket Volume. Price in j)apor covers, 30
" HexiMe cloih, 5i)
ThH little bu<>k \f intended to place in the hand'« of proP'risionAl men and othoM the me^'uiB of anttrf-rinf
•atisfii^'toiily and intellii^entlv uny iniiiiri<K tli.it may !>•• iiia'i«f of thcni in c<)nue(:ti(in with thin iu)i->rtjnt
tnbjwt.
Holmes' Surgical Diseases of Infiincv and
Childhood. By J. TIolmes. M.A., Surgeon to the Jl'spif'l fo-
Si.'k Children^ d:c. Second Edition. Pevised and Enlarged. ()«;avo.
Prit'o, ;?9.00
Ilufeland's Art of Prolonging Life. Ed.t^dbv
Erasmus Wilson, M.D., F R.S. Author of ''A S(/st>m of llfnnnn
Anatomy,'' '* Diseases of the Skin,'' &c., &c. 12nio. Cloth. $1/25
LINDSAY AND BLAKISTON'S PUBLICATIONS.
Mackenzie on the Laryngoscope, Diseases
of the Throat; &c. Second Edition.
The Use of the Laryngoscope in Diseases of the Throat, With additions ^
and an Essay on Hoarseness^ Loss of Voice, and Stridulous Breathing
in relation to Nervo- Muscular affections of the Larynx, by Moreli.
Mackenzie, M.I)., Physician to the Hospital for Diseases of the Throat,
Sc, &c. Second Edition, with additions, and a Chapter on the Nasal
Passages, by J. SoLis CoiiEii,MA)., Author of '* Inhalation, Its Thera-
peutics and Practice, ^^ (he. lUustratrd by two lithographic plates, and
51 engravings on wood. Octavo. Price, . . . .► $3.00
** Wbll<it Inryngoionpj wm in its {nfnncy, und hffiire it hiul bogiin to eiifmgo to any extent the attention of
the Prur«»!iii«in. it win* ritinliiHl wifii tlio Krnatt-Ht '-.iro hiiiI (rritliu!ti:i''ni l)y th«- iiutlinr of thiri trinitino. A per-
tnual flrifiicj of CKt^rniak'n, wh<» h>u« iIoih^ iiiore th:<ii any oihur c«)ntiiii'ntHl pliyHirian to intnNluco the larynica-
•co|H> into pnu'tici*. Iii.> hiv protiiol it\ tlii' opp >rtuiiitif!< wliirii he tiiiiH |i<M<ii-.>«Hf<l of Itccotuini; uc piHintiHl with
tlie imatuniy iukI niorl>i<l Hnalomy ol tiie larynx. But he halt done much more tlum thi«. As will bu MX*n by
a iierus.ll of thi« tre-atise, lo* h<ut nioi|itic<| thi> in-^tniiufntd ut ])i*us-nt in uhh for tho exiiminatiun of the
Uirynx, and htm inTi'nte<l otherH for thcrMiH-uticuI pnrpt ti-K. TIiosa yhn are anxious to study the disMum of
the larynx and the nifKln of lining the liiryn;;<>nc«>pt%«'iinno' ihi better than purcha-^e tlie tretitise tM*fore us, um it
b by far the best which had been publi(<licd, and is thoio* ^hij to be relied Ui)ou." — Glasgow AlatiaU JouriuiL
Morris on the Pathology and Therapeutics
of Scarlet Fever.
By Casper Mouria, M.D., Fellow of the College of Physicians of Phila-
. delphia, d'C, &c. A New Enlarged Edition, Octavo. . $1.50
Meigs and Pepper's Practical Treatise on
the Diseases of Children.
Fourth Edition, thoronghly Revised and greatly Enlarged.
By J. Forsyth Meios, M. I).. Fellow of the College of Physicians of
Philndelphin, d:c., (f:c.,and WiTiLiAM Pepper, M D,, Physician to the
Philadelphia Hospital, (<x*., drc , forming a Royal Octavo Volume of
over 900 pages. Price, bound in Cloth. . . . $6.00
Leather, . . . T.OO
Dr. MeigD* work has btKin out of print for sopie year*. The rapid tu\\o of the three previous editions, and the
great deniknd for a new edition, iit Mifflirieut evidence of itn grrat popularity: while the very large practic*
of nmnv yj-ar-*' •*tan«linjc «»f tin* mithor in th« j«pK'lality ol ** I)i!«tiw«>f» of Childr»*n," imparts to it a value un-
•««|nall«'d.'|irol»nl»ly. Iiy any ntlu-r work «»n thfuanicKulJfut now l»efori«tlie Proft'Ksion. This present edition bat
been ulin«><it iMitirfly rewritt*>n lUd rcarninKed. and no ofTort or Labor has been spared by either Dra. Meigt
-tr I'l-pi*'*''. to niakeit represent fully in its most advance*! state the present oundition of Medicine m i^tpUei
to ChiUbx*n's Diseases.
Murphy's Review of Chemistry for Students.
Adapted to th^^ Coxmes as Taught in the Principal Medical Schools in the
United States, By John G. Murphy, M.D. In One Volume. $1.25.
** This is an exceedingly well-arranged and converlent Manual. It givet the most Important fhcti and
princlplfs of Chemistry in a clear and very concise manner, so as to sobserre moat admirmblj the object §0$
vbicb It was designed " — ybrth Wutem Mtdieal and fiurgical JoumaL
Maxson's Practice of Mctlicine.
A Neu. Texl-Bo<ik on the Prarilre of J/ediVin*. Bj Edwut R SUxkw,
M.D.,/omuT/:j UrlUTtr oil the In«tltuSe»and Pi^ftirt n/ Uedia»t in lig
Geneva iledieal ColUye. In One Volame. Rvral 8to. . HM
Mcndcnball'silcdical Student's Vadc Mccum.
A ChmpmiUum of Aniilomij. I'h<j-i<.t.,y;i. C'>nni,ilri/. The I'mHlfe oj Urii-
due, Hurr/ery, Obeivtrie*, Jtinfisr* vf Ihf Utin, ilalerlii iltdiea, Jitm*-
■ iwacy, /'owofu), ttc. (t-c. I!v tiKtiiniE MrNDtSU.vi t-. M,U., /Vo/mwri/
ObtUtriet in the MtdlaU CUlr^e of Ohh, MmiSer of the ^nrnM»
iledUat AiMKiatlon, ie., i(c TJie Eighth £dUu/n, Jterutd mnd E^
larged; with 224 J Uuntraluiii*. t£M
Pa;^et*s Lectures on Surgical Padiology.
Delivrred at tho lioyal Collr-ge of Sur^fotu of Eny/and. Iiy jAMct Ptorr,
F.U.S., Surgeon to BarthaUtmnB and titruft Hospital, <It, ^t. TU
, Third American from lite HeeoiiU LoHdon £dUion, Kdiifd etnd t!<wimd
by William Tuumer, M.U., Lond. Stnior Dmnoiuitrator of Atmtimj it
tlie Univemiti/ of Edinburgh, dc, id. Ja One VoluiM, Sojai Ottam;
with !Cuvtcrou» Illiutrnliwia.
Price, in bevelled doib, I&M
" in kailicr, , TJJ$
Pennsylvania Hospital Reports, warfftyacb*
miHfr of the B'>*}nlal Slaf. J. M pAroaTA. M.I> , and Wiluaji Hmrr.
XI, I). VoIk, 1 and 2. for IHGn and }>ie,9.To-b vnlumi' (^nlaininy wpttarit
of rwonly Original Arlwlrn. by former end pr^-^rnt Mfmh.-r» nfikr .Srtjf,
now eniinenJ «n (A« Pro/wKion. u^A Lithographic and other tlturtr^l'om*.
Price p«r volume $4.M
Al lul. howsTrr, (he work b» b*en caimnenccd, th< rhilailrlpb ia PfaTviaiaB* bffcf
lbs Ural lu ucciipj ihii fir]ii of mo fu In ens, hiitlii|! IriurU ilir Br?l toIubf uf lb* Rir«tM
at Ibe abuxi bospital Uil f car. «ii<l iLe^eponJ >uliiiu<- ou Jaouar; lu. IHM Tba tnl
Kc|<DrU Wfro *0 raTorabl; rreviTxl on both siUta 9t ihv Allanlia, Ibai ii ta barll*
ntceHnrv lo apeak fuf ihii tdIuoh the unirrrial wcleome of obieb ii U <it
•Jaraliug ti
ting lha( Ihii papira arc all TBlnabtn cuain'qiliKi
ure of niaiilain*. rifleoliog gmt oradit upiMi ibctr auibur*. and ika aarfc
ill Ibo I'vunsjlraaia Ho<tiiTaI maj •ell b« pi-ou.i- U ■III Jo uiMb iiaaM
proreaaioD of Ihih Couiilr; in tlie r«llujatii>n of Ihair foralgn bMtkrvk."
— Amtrieon Journal af Oi4Utna, M*J, IttS.
LINDSAY AND BLAKISTOK'S PUBLICATIONS.
Pereira's Physician's Prescription Book.
Containing Lists of Terms, Phrases, Contractions, and Abbreviations, usei
in Prescriptions, with Explanatory Notes, the Grammatical Constructions
of Prescriptions, Rules for the Pronunciation of Pliarmaceutical Terms,
A Prosodlacal Vocabulary of the Names of Drugs, etc., and a series of
Abbreviated Prescriptions illustrating the use of the preceding terms, etc.;
to which is added a Key, containing the Prescriptions in an unabbreviated
Form, with a Literal Translation, intended for the use of Medical atid
Pharmaceutical Studejits. By Jonathan Fereira, M.D., F.R.S., ete.
From the Fourteenth London Edition.
Price, in cloth, 11.25
" in leather, with Tucks and Pocket, • • . 1.50
This little work has parsed through fourteen editions in London and sereral in this
eountry. The present edition of which this is a reprint has been carefully rerised
and many additions made to it. Its great value is proven both bj its large sale aad
the man J favorable notices of it in the Medical Press.
Physicians Visiting List. Published annually.
SIZES AND PniOlii.
For 25 Patients weekly. Tucks, pockets, and pencil, $1 00
fiO " ** ** ** " 1 26
75 " «« «« " *« 1 50
100 " " " " ** 8 00
50 ••
100 "
<i
SM
Also, AN INTERl^EAVED EDITION,
for the use of Countn/ Pht/nicians and others who compound their own Prescriptions,
or furnish Afrdicinra to their patients. The additional pages can also be used for Special
Memoranda, recording important cases, &c., &o.
For 25 Patisnts weekly, intsrleaved, tucks, pockets, etc., $1 50
50 *« •* •♦ . •• »» •• I 75
so •• " awl'lJS'ytoJS''}" " »••
Prince's Orthopedic Surgery.
Orthopedics: A Systematic Work vpon the Prevention and Cure of
Deformities. By David Prince, M.D. WOh Numerout Illiutratiotu,
Octavo 13.00
**Thi8 is a good book, apoD an Important practical subject; carefhily written, al)andantl3r illnstrated, and
well printed. It goM orer the whole ground of doformities of nil degrees— from clefl-pAlate and clab-fbot, to
•pinul curvatures and unuiiit«>d fractures. It appears, morooTer, to be an original book, so fiir an one chiefly
•f compilation can bo so. Such a book was wanted, and it jleserrw rocoen." — Med, ^ Airg. BeporUr.
Prince's Plastic Surgery.
A New Classification and a Brief Exponiion of Plastic Surgery. By
David Prince, M. D. In One Volume Octavo. With Numerous IIIub*
trations. Price,
8
LINDSAY AND BLAKISTON'S PUBLICATIONS.
Radcliffe's Lectures on Epilepsy, Pain, Pa-
ralysis,
And certain other Disorders of the Nervous Sifstem, by Charlks Blanp
Radcliffe, M.D., Fellow of tJie Royal College of Physicians of London,
Physician to the Westminster Hospital, etc., etc. With Illustrations,
12mo »2.0!)
'*Tliti reputation whicb Dr. Radcliffe poMcssea aa a very aMp authority on nfrroua affections, wtll cmnmend
ku work to evi'ry mediml practftioiier. Dlnonlem of the nerrou*" nyHtem are very Imperfectly compreheni!**!,
mncli ctincoming them Wiug involved in myNtcry ; and while Dr« Radcliffe hiia taken advantage of the ample
niom to theorixe, which his mibject afforded, he has not failed to hririK forvrard stmng and fnruiidalde facta to
prove the deductions he attempts to draw. Wo recommend it to the notice of oar readers as a vrork that will
throw much light upon the Physiology and Pathology of the Nervous System.** — Oinada Medical Journal
Robertson's Manual on Extracting Teeth.
Founded on the Anatomy of the Parts involved in the Operation; the Kinds
and Proper Construction of the Listruments to be used; the Accidents
liable to occur from the Operation, and the Proper Pemcdies to retrieve
such Accidents, By Abraham Robertson, D.D.S., M.D., Author of
''Prize Essay on Extracting Teeth" dx. In One Volume, with Illustror
tions. Second Edition. Revised and Improved. , . $1.50
" Tlie author \* well known as a contributor to the literature of the Profession ; and, as a clear, tetw, for-
cilil»' writir, he luui «li«viili'd conslderjible care to the subject, and trciitrtl it with hid usual ability. The work
fi vahuilib', not only to the dental studi lit and practitioner, but also to the medical student and aurgcun; and
•apeciidly so to the nillltJiry surgeon, who, in times like the present, is called upon fo frequently to perfbra
the o|N;ration of oxtructiug teeth." — DtrUal Qamot.
Ranking s Half-yearly Abstract of the Medi-
cal Sciences.
Price, per annum, if paid in advance, $2.50. Half-yearly volumes, $1.50.
The Grst thirty-two volumes, bound in sixteen volumes, leather, can be
furnished each at $2.00. Half-yearly volumes, in paper covers, from 1 to 34,
»ach at $1.00.
Renouard's History of Medicine.
History of Medicine from its origin to the Nineteenth Century. With an
Appendix containinrj a Philosophical and Historical Review of Medi-
cine to the present time. By P. V. Renouard, M.D. Translated
from the French by CoRNELirs G. Comeoys, M. D., Professor of the
Institutes of Medicine in the Medical College of Ohio, etc. In One
Volume Octavo, Price, $4.00
" From till- pHgHfl of Dr. Renouani, a rery accurate acquaintance may be obUined with the history of meib-
dne — it!! rrhitlon to civlllTuitlun, its prnxress comparHl with other sciences and arts, its most diftintniisheil
eoltiTators with the severnl th«H>ries and system^ proposed by them, and its relationship to the reigning phll-
oiophiral dogiijim of the s^venil p.-riods. ilia historlrul narrntiun is clear and concij^e, tracing the [.n-crces
of niHicino Hin.ugh itn thtee a^es or epochs — that of foundation or origin, that of tradition, and that of
renovation.**— .«4mrrican Journal 0/ Medical Sdenot.
"The best history of medicine extant, and one that will And a place In the library of erery physician who
tlma at an acquaintance with the past history of his profession. There are many items la it we should like
lo oier for the instruction and amusement of our readers."~^m«ncan Jowmal qf Pharmxtv.
XdNDSAY AND BLAKISTON'S PUBLIOATIONS.
Ryan's Philosophy of Marriage.
In its Socialy Moral, and Physical Relations, with an Account of the Dia-
eases of the Oenito- Urinary. Organs. The Physiology of Generation in the
Animal and Vegetable Kingdoms, &e,, &c. By Michael Ryak, M.D.,
Member of the Royal College of Physicians and Surgeons in London, <fcc
12mo $1.00
** Dr. Ryan to aboTt reproftch or tuipicioB : and with a ainguUr degree of candor and independence, ezplalM^
ki a true and philoeophical nuuiner, eTery branch of the aiil(ject whkh he conaldflra eaeential to be nndfl^
itood by all intelligent persona^" — Botton Medical and Surgical Journal.
Reese's Analysis of Physiology.
Being a Condensed View of the most important Facts and Doctrines, do-
signed especially for the Use of Students. - By John J. Reese, M.D.,
Professor of Medical Jurisprudence, including Toxicology, in the Uni"
versiiy of Pennsylvania, &c.,&c. Second Edition, Enlarged. 12mo. $1.50.
Reese's American Medical Formulary.
12mo $1.50
Reese's Syllabus of Medical Chemistry.
$1.00
Stille's Epidemic Meningitis ;
Or, CerebrO'Spinal Meningitis. By Alfred Still^, M.D., Professor of
the T/ieory and Practice of Medicine in the University of Pennsylvania,
&c. &C. In One Volume Octavo. $2.00
" This monograph is a timely publication, oomprehensive in ita scope, ftnd preseDtlng within
% imall compass a fair digest of our existing knowledge of the disease, partioul&rly acceptable
%X the present time. It is just such a one as is needed, and may be taken as a model for similar
works." — Am. Journal Med. Scxeneet.
Sydenham Society's Publications. NewSeHesASb^
to 1870 inclusive, 12 years, 60 vols. Subscriptions received, and back
years furnished at $10.00 per year. Full prospectus, with the Btportg
of the Society, and Lists of Books publislied, furnished free upon
application,
Stille's Elements of General Pathology.
A Practical Treatise on th^ Causes, Forms, Symptoms, and Results of Dis-
ease. By Alfred Stillk, M.D., Professor of the T/ieory and Practice
qf Medicine, in the University of Pennsylvania, Ac. (In Pi^eparation.)
LINDSAY AND BLAKISTON'B PUBLICATIONS.
Sansom on Chloroform.
Its Action and Admini^ratwrif by Arthur Ernest BAiiBOMy M.IL,
Physician to King*s College Hospital, etc., etc 12mo. . . S2.(H)
"The work of Dr. (^nMnn may !•« chiu-acterized m most excellent. Written not a]on«> frimi a tbcorrtieal
point of view, l>ut Hhowiiig rery cotisiiltrablv ezi>erimfntrtl »tu<Iy, «ii<l an intiniHte rliDicni acqaaintaoce wuk
tile adniiiiiHimt<nn of tl)i««« reiui-die*, — p»w>iii;; conri-^-lv orm the wbole grfnind^friTiut^ th«» Intent ^nfnrmKtK-'ff
ipon erery pf )iut, — It la jatt tht* work for tlie atndent and pmctitloner. The aotlior may rvnt aaanred that,
■Itbongh in liiii preface he ot»Jects to the Miackneyed expreMton of endeavoring to supply a want.* thia u jtal
what he haB done — lupplied and well tnpplled a want, fbr no aooh hook existed hefore in our laBgnafB.**—
American lltdical JoumaL
Scanzoni's Practical Treatise on the Diseases
of the Sexual Organs of Women.
Translated from the French of Drs. H. Dor and A. Socik, and annotated
with the approval of the authors. By A. K. Gardner, A.M., M.D.,
Professor of Clinical Midwifery, etc., etc., in the New York Medical Col-
lege, With Numerous Illustrations, Octavo. • , . $5.00
In the etiology, pathology, and therapeutics of female diseases, with all the im-
proTcments which haTC been realized during the last twenty years, this Tolume is ex-
ceedingly rich; while in its arrangement it is so methodical that it must constitutf
one of the best text-books for students, and one of the most reliable aids to the busy
practitioner.
Stokes on the Diseases of the Heart and the
Aorta.
By William Stokls, Rcfjhis Professor of Phy*ie iv the Univ€r.iity of
Dublin; Author of the Treatment and D'agnosis of the Diseases uf tlie
Chest, &c., &c. Second American Edition. Octavo. . , $3.00
Spratt's Obstetrical Tables.
Con^jtviaing Graphic HI ut>f rations, with hesrriptions and Practical
Binaries exhibiting on Disnerfed Plates many important subjects in
Midwifery. By G.Svkatt, Surge.on Accoucheur, First American from
the Fourth and Greatly Improved London Edition, care futly Revised,
with Additional Notes and Colored Plates. One Volume Quarto.
Price $S.GO
Skoda on Auscultation and Percussion.
By Joseph Skoda. Translated from the Fourth German Edition, by
W. 0. Markham, M. D., Assistant Physician to St, Mary'^s Hospital.
l2mo $1.50
UHTCAT AND BLAKISTON's PUBUOATIOiro.
Tanner's Practice of Medicine.
FII*TH AMBRICAN BDITION.
The Practice of Medicine, by Thomas Hawreb Tannsb, M.D., JPellaw
of the Royal College of Phyfncians, Author of A Practical Treatise on
the Diseases of Infancy and Childhood, etc, etc. Fifth American from
the Sixth London Edition, Oreatly Enlarged and Improved,
Price, bound in cloth, (6.00
" " in leather, 7.00
Dr. Taoner*8 work on the Practice of Medicine li bo well known in this country, and
ha« had such an eztensiTe and rapid sale, that it seems almost unnecessary to say any-
thing in reference to it; the present edition, howeTer, contains such substantial addi*
lions and alterations as almost to constitute it a new work, and from being a com-
paratiTely small volume it now forms a handsome octaTo of nearly 1000 pages ; all
that was useful and practical in the smaller Tolume has been retained and much new
matter added, written in the same condensed and easy style.
"The iMMllng ff«tur« of this book la its «iiN<>ntiiilly pmctiml chRrncter. Dr. Tanner hM prodnced a nor*
eomplete Sjrstem of Medicine thun iiny with which we are srtjniiiiited. It is the renultof long experience and
hard practice, and It is tberefbre valoable as a guide, and tnutwurthj as an exemplar.'* — *jimdoH LanctL
Tanner's Practical Treatise on the Diseases
of Infancy and Childhood.
Octavo $3.00
This book differs from other works of the kind, in embracing a wider range of sub-
jects than is usually contained in treatises on children's diseases; besides the ordinary
eomplaints of those subjects, it includes many uUections which, though common to
^ults and children, yet otTer some modification in form, or in the indications for treat-
ment, when occurring in the latter. Thus, we ha^e an account of diseases of the eye,
ear, and skin, of small-pox. scrofula, tuberculoHis, syphilis, bronchocele, and cretinism,
diseases of the kidneys and genital organs, and some of the accidents common to child-
hood. The style of the work is condensed, and the book might with truth be called
a manual, rather than a treatise, but there is nothing superficial about it; — every-
thing really iniportunt is given, while the discussion of disputed subjects, ^nd, in
fact, of everything which is not of practical importance in the study and treatment of
ohildren's diseases, is omitted.
Tanner's Index of Diseases and their Treat-
ment.
With upwards oj 500 FormuUz for Medicines^ Baths, Mineral Waters,
Climates for Inmlids, Ac,, &c. Octavo $3.00
" Dr. Tanner tiaa lK«n pecnliarly happy in appreciating and supplying the wants of the Profession. Illi
ludf'x cf Diseases glvt^ the derivntioii nf words after the manner of a good Medical Dictionary; an outline of
evt-ry dlimse, including many surgical diseaKiii, with their iyroptoms and mode of treatment; an adniirahls
collectiuu of Fuimulasand an account of the climates of the various parts of the world sultahle for InTalida. It*
also nmuius at the iMfgiuning of the worli a tabular synopsis of subjects, which does double duty at onee, a
Nosology and an index. It will be fonnd a most valuable companion to the Judicious practitioner.**— Zofioet
Tanner's Memoranda of Poisons.
Frcna the Seecvi Jtondon Edilion. . . .... $0.60
LIWB8AT -AHfD Bi/ArfBTOlTB VdlAOAtt^ti.
Trousseau's Lectures on Clinical Medicine.
Delivered at the Hold Dieu, P'lrM, hj A. Trdusbeau, Professor of Ctini
cal Medicine in Hie Faculty of 3Iedicine, Parig. Translated and edileH,
with JWss and Appendices, by P. Victore Bazire, SLD., A»n*ttni
Phyfrlciait to the KatiotuU Hospital for tliA Paralysed and Epileptic, ^
Volume One. Cloth 5 00
Volonie Two, 6 00
Volume Three, now Reftdy, 5 00
* nti boak [limliihG* u* vrfth an flLanipla of the tiwl kind of cUitlcal t««o]iIiic, vtd «« are BiKb t-^^.^
to lh« truulnlnr fur lupjiljlns Ihs I'rDfmilon iriili thiu uliuinblr L^'liitA Ii !• ■ l^i-ik irhl<b duM^witr
kt pepDluunL Wntehmly kDo* nrnnjiiLirkbi-ltH'filb'<l(iir[irMiq.liiiloii Id ■ f>:iiBg nmn vbi-o •■un^
■poo Ike tnnctlenl work 0( Iii< ll(>. TbedeliBnllMior IbBKo'iM «■» !• icnphiD. •nd Ibdr iumlHa«»
B*ol(|Mllg topuJut loipncUCMl iMHin." — ZenAM MuUait nmadnd CailU.
Tyler Smith's Obstetrics.
A Course of Lectures. By William Tylek Smith, M.D., Pht/ti^dn, ,
eouclifvr, and Lecturer on Midu-ifery, and the D'i»ea«e« of Females, in SL
Mary's Iloiqiital, M-xOcal School, &e., i'c. With Kumerout TUuArutim*.
Edited by A, K. Gahdneh, M.D., Fellow of the A'rsw York Academy of
Medicine, tto., dc. Octavo. (5.00
Toynbee ou Diseases of the Ear. TkHrKaturt,
Diagnosis, and Tr'salmcnt. A new London Edition, wilh a Suppln-
menl. By Jamrs Hinton, Aural Surgeon to Guy's ffoxpitai. Ov. iVUh
Hiuilrations, Octavo, .... Pripe, 1.^.00
Thompson's Clinical Lectures on Pulmonary
Consumption. octavo. j2.oo.
Tyson's Cell Doctrine:
Its ffinlorij and Present State, with a Copiovn Bibliography of the Svih
ject, for the use of Students of Medicine and Dentistry. Uy Jamu
Tyson, M. D., Laoturer on MicroKopy in the Vnioertily of Pentaittl-
vania, dc, itv. In One Volume, with a Colored Plate, and nuini-ruuM
Iltuslrationa on Wood. Prioe, ..... $4J)0
Tilt's Elements of Health, and Principles of
Female Hygiene.
By F. J. Tilt, BLD,, Senior Physician to Via Lying-in Clutrity, AuAor
of Works on the Dieeases of Menttniation, Vltrine Therapeutit^ tfra,
Ac. 12mo SI 50
to tho ■cplennlA] epKbB wt>
cd bj pUlotopbm tuA msdini im, Jk
dtoiBWi Ac, pHnlLu' to iiiEb. Tb« St
□gch nbiil<l<iKJ<liBn«|-«citB(tb>ai«r
Ih stoat."— If. T, JbUcoI Timu.
LIKD8AY AND BLAKIBTOK'S PLALIOATIONa.
Taylor's Theory and Practice of the Move-
ment-Cure.
Or, the Trsaimeni of Lateral Charvature of the SpinCf Paralyeis, Indigestion^
Constipaiioni Consumption^ Angular Ourtaturea, and other Deformities,
Diseases Incident to Women^ Derangements of the Nervous System, and
other Chronic Affeeiions, by the Swedish System of Localised Movements.
By Charles Taylor, M.D. With Illustrations. 12mo. • $1.50
The work of Dr. Taylor is a systematic treatise, containing the principles on which
this treatment is based, and full and explicit directions in their application to indi-
lidual diseases. The author discusses the nutritive processes, muscular contraction,
and the physiology of general exercise, the subjects of the first three chapters, in a
most satisfactory i^nner. The work is purely of a scientific character, and commends
itself as such to the attention of all physicians.
Virchow's Cellular Pathology.
As based upon Physiological and Pathological History, Translated from
the Second Edition of the Original, By Frank Chance, B.A., M.A.,
Cantab Licentiate of the Royal College of Physicians, &c,, &c. With
Notes and Num.erous Emendations, principally from MSS, Notes of the
Author, and Illustrated by 144 Engravings, Octavo. . • $5.00
Prof. Yirchow and his writings are well known whereyer the science of medicine is
•tndied. This work has been selected by the Medical Bureau of the United States for
general distribution in the hospitals and medical stations of the army ; recording, as
It does, the researches in this branch of science down to the present time.
The importance of the subject, the new ideas advanced, and the established repu-
tation of the author, induced the publication of this book, and has made it a standard
work throughout Europe and in this country.
Virchow on Morbid Tumors.
IN PBEPARATION.
Walker on Intermarriage.
Or, the Mode in which, and the Causes why, Beaiity, Health, and InteUeei
result from certain Unions, and Deformity, Disease, and Insanity from
otliers. With Illustrations, By Alexander Walker, Author of
" Woman," " Beauty/* &c., &c, 12mo. .... $1.50
** The anthor U •videotly a careful obaerrer, and a proper thinker, and has presented ne with a rast amonnt
•rinfm-niation, deriTed both from man and the inferior animals. lie haa aimed to be neefnl, by pointing out
flow bodily deformitiei and mental inflnnitiee may be foreHtalled; and how marriafea anions blood relatione
tend to the degeneracy of the offspring. lie alfto ihowB how, by cmreftilly aaaorted marrlogei, the means of
ImproTing general organization and beauty of countenance, aa well aa mental and physical rigor, are, in a
great degree, under the control of man. Although not strictly a medical work, we cannot refrain from ooni
■ending it to th» pvuaal of the Profeaalon, ■• It oontalna much thatliTaliiabldlnahyglaBic point of Tiew.''-^
i.nn»AT ASB mjiAximos'ti PtraiiioAnom}.
Wythes' Physician's Pocket, Dose, aud Sympj
torn Book.
Oanlaininff the Dotet and U»e* of ail the Prinffipal Ariicla of the Mali
Medial, and Original Preparallom; A Table of WeiejhU and J/ii
svres, Rtilet to Proportion the Dmet of Medicines, Common Abl>r
viation* ii»ed in Writing Preseripliom, Taitle of Poi«on» and Antidob
Clax^fieation of the Materia Medica, Dietetic Preparatifmx, Table ^
Si/iiipiomalology, Outltnet of General Pathology and Therapeittice, <
Bv .Jo9EPn H. Wytdes, A.3iL, M.D., Ac. The £iyhih lievi^ed Edilitt
Price, in cloth, SIJ]
" leatlier, tucks, with pockets, .... U
This lidle manual has been reoeWed wilh munh faior, and a largfl nutuber of cn|>
■old. Ii irai compiled Tor ihe aeelsianoa ofsiadenta, and to furnUh a *>de mecom I
the general praoiilloner, which would Baie the Irouble or reference to larger and m(
eluborale works. The present eUilion hns UDdcrgone a oareful reTigion. The Ihal
peu'irat arrangemenl of (he Materia Medica has been added to it. together wilh M
other improremeais as it wm (houghl might prove ot Ta1u« lo the wotc.
Waring's Manual of Practical Therapeutica
Considered chiefly ttUh reference to Article* of th« Materia Medica,
Edward John Warino, F-It-C-S., FJ^., &c., Ac. Prom (Ac Secoi^
London Edition, Royal Octavo.
Price, in cloth $6.0
" in leather 7.fl
L
There are man]' fealuroa in Dr. Variiig'a Thernpcutlcs which render it eapprial
Taluable to iLe rraoiitioncr and Student of Medicine, micb ImporiAiil and reliable I
fonaalioQ being found in it nol coolnincd in similBr worVs: it ulao diffprg from thi
io its oompletencas. the convenience of iu arrangiuneDt, and tha greater prominen
given to the medicinal Applicalion of the tarioua articlei of (he Materia Medina in i
treatment of morbid eooditione of Ihe Human Bod;, &o., ko. li is divided idId ti
pariH, llic nlphabetical ar ran gem ml being adopted throughai.t ihe volume For tl
further conveuieace of the reade- there is alto added an Ixntx or Uibiabo, willi
llHl of ihe medicioea applicable as remedies, and a full IHDIX of the mpdicioei aj
preparaiio&fl soliceil in the worli.
"ODiadiDlnHaa, doi oBI) lot [lis luiiniiiiia lulaalrr of Uiaanlbar, balalHaf Ihi gnKl pnotlAl nliw
K •'•n7 ■iDilsDl at pnctlllon-M' In Ibi cinmtr]'. iD oar Mllraatlon II Ii tha beU Iwk or Ib» klU «
Weber's Clinical Hand-Book of Auscultatioi
and Percussion.
An Exposiiion from Firgl Principles of Ihe McUiod of InirKlit/alit
JJi teasfn of the R'fpiralnry and OircvlatinQ Orijang, TrAnslnteii li
John Cockle. M, 1>. With III ugirationg. Prk-e, . . tl.(
LINDSAT AND BLAKISTON'8 PUBLIOATIOITB. ^
Walton's Operative Ophthalmic Surgery.
By Haynep Walton, F.RC^, Surgeon to the Central London OphthcJr
mio Hoisp'dcd, &c. With 169 lUudtaiiom. Edited by S. Littell,
M.D., Surgeon to the Wills Jlospital for the Duieasee of ike Eye, &c.
Octavo W.00
** It b MuinenUy a practical work, «TiDciug in iu Mitbor grMit rtMwrch, a tboroofb knoidadft of hk m^
}eel, auil no hccunite «ud uioflt oUMnrriDj^ nuiuL" — DuUin Quarterljf JtmmoL
Watson's Practice abridged.
A Synopsis of the Lectures on the Principles and Practice of Physic De-
livered at King's College, London, by Thomas Watson, M.D., Fellovf
of the Royal College of Phyaicians, &e,, <tc. From the last London
Edition, With a concise bid Complete Account of the Properties^ Uses,
Preparations, Doses, d:c,, of all the Medicines mentioned in these Lectures^
and other Valuable Additions, by J. J. Meylor, A.M., M.D., &c,, &c,
A neat Pocket Volume bound m cloth flexible, • • • $2.00
Wells' Treatise on the Diseases of the Eye,
iUuatrated by OphUialmosoopic PkUes and Numerous Engravings on
Wood. By J. ScELBEUO Wklls, Ophthalmic Surgeon to King's College
HoapHal, dec. Second London Edition, cloth, $6 50; leather, $7 60.
ThiM is the author's own edition, printed in London under his Bupervision, and issued
in this country by special arrangement with him.
Wright on Headaches.
Their CaxLses and their Cure, By Henry G. Wright, M.D., Membei
of the Royal College of Physicians, &c, &c. From the Fourth London
Edition. 12mo. Cloth $1.25
*< Few affections are more unmanageable and more troublesome than those of which
ihifl essay treats; and we doubt not that any sujcgcstions by which we can relieve
them will be gladly received by physicians. The author's plan is simple and practical.
He treats of headaches in childhood and youth, in adult life and old age, giving in
aach their varieties and symptumsy and their cuuseb and treatment. It w a most satis-
factory monograph, as the mere fact that this is a reprint of the /owrM edition, testifies.
*'The great pains which the author takes to clear up the differential diagnosis of the
ditfcront vurieiios, and establish a s'iiisfaciury basis for rational treatment, are every-
where visible. While such a valuable fund of information is offered to the practitioner
ii iht» cost of a single visit, he should uoi lei his patient suffer for want of it.'* —
Mtiiii'ti and Surgical lUporter.
Wells on Long, Short, and Weak Sight, and
their Treatment by the Scientific Use of Spectacles. Third Edition Re-
vised, urith Additions and Numerous Illustrations, By J. Scelberq
Wells. Octavo. ..... Price, $3.00
1iI3rDeAT AND BLAEIOTOV'S PtTBLIOAnoKTB.
Harris's Dictionary of Medical Terminology,
Dental Sdeoert, and the Coi-laterat. Scienceb. By Chapis A.
Hareis, M.D., D.D.S., PrQfe»»or oj Ihe Principle* of Dental Suryery tn
the Balltmore CoUtge, Member of Ihe American Medical Agsociation. At^
&G, The Third Edition, carefully rented and enlarged, by Ferdi-
MAND J. S. GORQAB, M.D., D.D.K, Profe^r of Dental Surgety in iU
Baltimore College, d-c, &c. Royal octavo. Cloth,S6.50. Leallier.Si.M
This DiciioDarj h«a been for » long limE out ot print : k new edition bai beea miek
Dcedeil bj Ihe ProfeHsion, a oonfltanl aod increAslDg decaiiail eiiBling Tor !L Th« preh-
eat edition has been tbomugblj' rcTised b; Profcsaor Qorgas, Ur. UurriB's BuooBSMr ia
(he Ballimore Dental College. Manj addiilong and correclioiiB haro been tnada, and
same :vo to three ILouganJ new words udded. The dasps afltie more promiiteDl medici-
nal agen'B haxe also been aJJed, and in Bxery waj th« book baa been greallj im-
proved, and ill value enhanoed.
Harris's Principles and Practice of Dental
Surgery,
The Ninth Edition, tm'th 320 Illustrations. Royal octavo.
Pric«, bound in cloth, bevelled boards, .... $6.08
" leather 7.00
This edilion of Dr. narris'a work has beeo suhjecled to a yerj thorougb re™ioB
by compeleot profesBJooul genllemen. and conlftinB many and important addUioia,
bringing (he work fully up to tbe present slate of dental Boienoe. and udillng gr«alJy
to ils value. Tbe illustraiinns have also been much improved; some bave been replaced
by new drawings, and many new ones have been added. Tbe piihlisber» Iberefor*
offer it with Ihe conEdenl assiirance tfaat it wit! now be found a tbarough element>r|
Ireaiife. a text-book for the student, and a aseful companioa and guide for (hi
Bond's Practical Treatise on Dental Medicine.
Being a Compendium of Medical Sei^nee, as Connected with Ihe Study of
Dejiial Surgery. By Thomas E. Bond. M.D., Professor of Special
Pulhology and Tlterapetttics in t!ie BaHimore College af Dental Surgery.
Tlie Third Edition. Octavo. 83.00
shiIkI to ipwk. baortll)' lo inlH
I of a c«pllal iDtbrnbli* In
Robertson's Manual on Extracting Teeth.
Founded on the Anatomy of Ike Parts involved iw Ike Operation, the Kindt
and Proper Construction of tlie Tndruments lo he Used, the Actidetitt
likely lo occur from ths Operation, and the Proper Remedies to be Used-
By A. Robertson, M.D., D.D.S., &c. A Nbw Hevist-d Edition Jl,;)0
LINDSAY XSS> BLAKISTON'S PUBLIOATIOKS.
Taft's Practical Treatise on Operative Den-
tistry.
A HEV EDITION, THOB0UOHI.T SEVIBED.
By Jonathan Taft, D.D.8., Professor of Operative DenJddry in the Ohio
College of Dental Surgery ^ &e. The Second Edition, thoroughly Revised^
with additions, and fully brought up to the present state of the Science,
Containing over 100 Illustrations. Octavo. Leather, . . $4.50
**An examination of Mr. Taft*i tr«itiM enablra as to ipcak most fkTorably of It. It to Tery thorough and
rery clear, showing that the author to practical ij Ihmlliar with the art which he teachea. The engraTinp
are abiimlaut and excellent, and, in (act, the whole mechanical exeni;lon of the toIqiim to admirable^ and
raOecta much credit oo tha pnhU»hm.**—Bo9Um ilatficai mnd Surgieai-JtmrnoL
Fox on the Human Teeth.
Their Natural History and Structure, tlie Treatment of the Diseases to
which they are Subject, the Mode of Inserting Artificial Teeth, &c Edited
by Chapin a. Harris, M.D., D.D5., &c With 250 Illustrations.
Octavo $4.00
Richardson's Practical Treatise on Mechani-
cal Dentistry.
SECOND EDITION, MUCH ENLAJftOn).
Bj Joseph Richardson^ D.D.S., Professor of Mechanical Dentistry in
the Ohio College of Dental Surgery, &e. With over 150 beautifully exe^
euted Illustrations. Octavo. Leather, . . . . $4.50
Haiidy's Text-Book of Anatomy,
And Guide to Dissections. For the Use of Students of Medicine and
Dental SurgeYy. By Washington R. Handy, M.D., laie Professor of
Anatomy and Physiology in the Baltimore College of Denial Surgery.
With 312 Illustrations. Octavo. $4.00
Coles on Deformities of the Mouth.
Congenital and Acquired^ with their Mechanical Treatment, By James
Oakley Coles, D.D.S., Member of the Odontological Society, &€., &c.
Second Edition, Revised and Enlarged, with 8 Colored Engravings
and 51 lUastrations on Wood. Price, . . . . $2 50
Heath on the Injuries and Disesaes of the Jaws.
The Jacksonian Prize Essay of the Boyal College of Surgeons of Eng-
land, 1867. By Christopher Heath, F. R. C. S., Assistant Surgeon
to University College Hospital. Over 150 Illustrations. Octavo.
Price. . . . $6 00
Tomes' System of Dental Surgery.
By John Tomes, F.R.8., Dentist to the Dental Hospital of London^ Avihor
of " Tamest Dental Physiology,** &e., &c With 208 beavJtifuUy executed
lUustraHons. Octavo. $4.60
LtirtMAT AMD BLAEIBTOH'B ?VBb10Att<Mft.
Cooley's Toilet and Cosmetic Arts. '"
The Toilet and Owmrtin Arl», m Aneietit otirf Horltm T^ma. Witt
Revieiti of tlw. Different Tlu^irifs uf Beautv and evji'tout aliied Jnf^m
lion, Soria!. ffm/ieiiir, and Mtdieai. indiiding Jri^tntrtii^n* nuil Cautitm
rttprftinij the Sefcrfi'wi and Use of Ferfumr». (\iiimeties. and othrr T-M
Arlicla; atui a Cowprthaitive Co/lftdun of i-'annulu, artd IfrttJttMt
Jot iheir Prqxiraliini. Hy Akkold J. CooLt^l, Author of" (.^yrifpifdi
oj Uffei]ii»: /V(*M*.M, D-ita.aiid Ci>ll.,lcr„l Iu(.irvMiliuH,Af..in tht J'
ajid 3/«ini/ae(wrM." Will, ISDEX to about 5Ut)0 M<^ttert „J tnttrt^ V-
or Oiu<lt>n. Demi-Oi'Uivd H.i^
Ott on the Manutacture of Soaps and Candles;
Iileludinn the ilmd /?■*«*( Difovrrifn. rwhraein<i alt kind* vf OritMB]
Hard,'Soft. and Todet Si>np«, mqKeiaUy llfur m-xtc fry (Af (WJ JVvcmj
and the ifode^ of Detrcliiuj FnuHt iu the Sfaniijattvrirty m%it t^Mtkkm
of Tnllou- anil Vonipo-lte Camllm. l(y Ai«)i-pn Orr. />•(«««/ «J;
Amli/Heal Cheminl. 12nn.. With ftl antral iint». (Jim rwwly.) tt"
Tbc kUiliuT, ia prrpiiring Ihi« latiimv, h» brrn carclViI lo >)tp xlrar twi toM
rficouni uf lUe ftri ufBuapsiKl cHuiltr mtkiiig, hs suw |>n«ilimr. ^ ■■ taokkvlba •■ .
ftnJ eriiiiittl fiplmiiilunn of the luriom ni«iiipuUrion» ' ' ' '
by wliii-h iliey lire tifrciod. Muoli new DittUer h»s iluu
beT«r b«rurr (•uliliftbcU.
coTporatvd U U« hM^
Picsse's Whole Art of Perfumery.
Kli KSI.AKdKli
'. Methods <f Oblaiiiii,'j the Od.irn of Fin
' ' » f<rr Ihf A/.-,.
KUITIOR.
the itanvfaaluTe of I'lTfnmrs j ..
OdoTom Viner/rtri, Dn»lifriea», I'omatuni
(!■«.; fo irkirh ii added in Afrptiudix. tin , id' fnJ
EtHKiiee^. Act. Itv (J, W. Skittmus Pirsci , 1 J m»
AiiiMcaii fro7ii ike. Third London ^dUion. IL'iuu. H\;:i ,
IlhulnUioM. ........
Db. I'lERaa'a Toluine DuvnrB the entire f;r»uiii] of Itae sul^Mt ubod wbii
II ie lull ~-I L'sel'ul ami Curioun Inl'uruialiun. id.'.ludiiiit alto iBAaj: VkliwUi
tn I nlIl b<r founil of cqiinl Jai|iurlnuoi auU lulcrpRl lo ibe jnicilml nmn aa
critl reader.
Ovcrmairs Practical Mineralogy, Assaying
and Minini^.
With a Deseription of the Uxefid SHneralt. and fnttrwtiona far
aceordiiif/ to the »iinpU»t Methoda. By Krujekick OveBSUS, Jfi<iut
Engiiteer, &c. 12mo (LA
Thi! objm of Ibis Tnliimc U lo plac* baTare <ha publio tb« rtua«IM4«[«a tsJ *■
«f mlDrrnla. in a pupulur iijile. aroiding. ^a far ai poaubl*. lb* n** uf aciMMilc aid
lecbQlcal icrimt. Tb« aub>ci in diiideJ iuio Ihreo piknoi — Mtarr«l«gj. •■r* Pnoi^
il'in ofihr A |>i>Mkratiav of Minerak wiih ib« loculiiin io wbkb ib^«iaj>-i taaakMl
foun'.l; .Awnjing, or %D InTCBii(r«(inii nt Ihe »h1u? of illmrala, bj n«aiu wfcWh »— ^"
If iihin Ibe reaeb ot evefj on« ; and I'ntalical Uiuing in iii ateiplMt (Mm.
Pigj^olt on Copper Mining and Copper Ore.
Co'iiuiinn/j a fuU Oaerijitlun of mutofthe Vrineipat Vf/yper Mine^tftht
VniUd Sla!rj. the Art of Miniii/;, Ihe Jfode of Prrparit^ tht Or* ^,
Ljrwto. tie.. &f. B; A. SNOwDict Ptnoorr. H.D., PratiiMt CktKitL.
LINDSAY AND BLAKISToN'S PUBLICATIONS
Morfit's Chemical and Pharmaceutical Man-
ipulations.
A Manual of the Chemical and Chemiea-ifechanical Operations of the
Laboratory. By Campbell Mobfit» Profeettar of Analytic and Applied
Chemietry in the University of Maryland, assisted by Clarence Morfit,
Assistant Melter and Refiner in the United States Assay Office, The
Second Edition, Revised and OrCaUy Enlarged, with ever 500 lUugtror
tions. Octavo $5.00
** Tlie armnfrement of the whole is fiich, that ererj •tadent will be able to go through the work withont m
guldo to leetl him, providMl the oeoemary apiNiratua are at hia command. But even without them, a careftil
•tii«iy of the hook will give the attentive stun^nt a rwj usefW Inaight in all the manipulMtiona of thephftrma*
eeutical chemiet, and thousands, no doubt, who- are prevented f x>ni attending the schoola (^ hamuic j and
oheniistry, will gladly avail themselves of the only means left them for self-unprovement. TLe amount of
pemeverance and iudnstry diiiplayed in the getting up of this work is truly astonishing, the cleamt^s of e»-
ureasion in every sentence, and the accuratenees of the 600 il lustrations, are al>ove praise. ' Morflt's Jtlanipnl**
BODS ' ranges in ntiUty Immediatelj after the United States OispeDsatory." — Ckwmiaal Oatttte.
Branston's Hand-Book of Practical Receipts.
A Manual for the Chjemist, Druggist, Medical Practitioner, dbc, (he.
Comprising the Officinal Medicines, their Uses, and Modes of PreparO'
tion, and Formula for Trade Preparations, Mineral Waters, Powders,
Beverages, Dietetic Articles, Perfumery, <jbc.; vxUh a Glossary of
Medical and Chemical Terms, and a Copious Index, By Thomab
F. Branston. From the Second Revised and Enlarged Edition,
12mo ... $1.50
CampbelPs Manual of Scientific and Practical
Agriculture.
A Systematic Arrangement of all Scientific Kno^oledge hearing in any m^n-
Ther on the great work of Farming, For the use of Schools and Fanners.
By Prof. J. L. Campbell, of Washington College, Vcl, 12nio. With
lUustrations, . $1.50
ThiB Tolume has been prepared to supply thooe already engaged in the culture of the
8oil with a guide, the study or perusal of which will enable them to improve upon the
old system, or rather want of system, whicl has worn out so much of our be^it land,
and has rendered the pursuit, in so many instances, unprofitable; and also to meet the
demands of teachers for a text-book of the right kind, which will give the student such
information as will fit him for the intelligent pursuit of agriculture as a busiut-i^s.
Darlington's Flora Cestrica;
Or, Herborizixo Companion. Containing ail the Plants of the Middle
Stat^, their Linncean Arrangement, a Glossary of Botanical Terms, a
complete Index, etc. By William Darlington, M.D. The Third
Edition, enlarged, 12mo. . . . . . . . $2.25
Miller on Alcohol, and Lizars on Tobacco.
Alcohol: Its Place and Power, By James AIiller, F.R,S.E., Profei^sor
of Surgery in the University of Edinburgh ; President of the Medico^
Chirurgical Society; Author of Miller's Principles and Practice of
Surgery, etc,, etc. The Use and Abuse of Tobacco, By John Lizars,
hde Professor of Surgery to the Royal College of Surgeons, etc, etc. The
Two Essays in One Volume, l2mo $1.00
The first of these treatises was prepared by Prof. Miller at the request of the Scot-
tish Ti'iiiperance League, who were anxious to have a work of high authority, present'
iiifS the medical view of the Temperance question. It has passed through a grest
number ot* fditiouH in Scotland, and has had a large sale in this country. The aeoond
^ao prepared by Prof. Lixarfl to show the pernioioua consequences of eicessite Off
bftbiiii'il imoking. If purchased In qwrntUUi, either together or separately, by TUimr.x
ptroHce or other sooietiea, they will be ftiniished at a reouoed price
NEW SYDENHAM SOCIETVS PDBLICATIOXS
UNSSAY & BLAKISTON, Philadelphia,
Arr now prepnrsd lo rccrire lu baa rip linos fqr ih« |iiib)i(i>lioii* at Tbi Vtw tn
B:Ui Sooitrt toT llic jt»T I BTO, a> TV" Oeltatt. fny».\i\t in eurranc}', ■fed Innrirtij ■
kdrnnoe, nnJ la rurnieli any of llie prcvioua jcari M tbo »ma rata sail an ll>« ■»•■
I'bc Pritc(ic4l Cliaracter nii^I Permancat Value of lh«40 paMiMttoo*. aad U* nqj
low priop 111 whhh Ibcjitrcfuriiiilieil. ooDimead thtm to ibc faTomM* MacMkaWtk
Hedii3»l ProfeloioD in ihe Gnited Su>t«a,
WOBES ALBEADT PUBLT8EED.
UMl (/Ynl !>«-.)
Vte. 1. IJn>itonInf>nlll>'5vi>l.lll*.
1. (loi;CMaBUI..uv-..'{tvll«ll.
i. Van i>» Kw.1 oa lb* hitmil Qgrt. Ac
t. Ho:i(Kiii>riii (KiHiiur k Tounn. OmK
,1^-111 o„ l>r.n» ..r III. Lint. 1
\ of f...llAll. lirSkln DlHMH.
iNmF,r,(r..in.nlt,l>«^b,lUitlrtH
»iliu.)
W Trar.l
11. Aliu ur l^iruniti al Skin rim in
fuicilu..}
IMS. iWi/tWraT.)
h. ». K«.Hiii ou DlH>»> iif tlM Ku.
Id. A VuHi»,ii(>-.FlIiU
K. Idrotcn Mid Voan sn th< flil».
'r*rlMX.
«.)
>i OWmwiI OB UmUl F^lvl>«T
■JD
TBt -IB, Tm Tol-l.-n
lum Dt Sell Dh
WORKS TO BE FUBLtSHBD IK ia7CK
Tronnesa't Olinic&l Medicine. Vol, HI,
Strieket'a Mauna! of HisWiogj. Tol. I.
Hiemeyet on PbtUiais.
Wonderlich'a Treatise on the Uie of the Tbermoinitei ta DUsuo.
A TeQth FuoiooloB ot the Atlu of Skin Di>e«aei.
luHUDntl so in •ililllluii lu tLu ml.
RoB-SBbMrlbcra .-» oIiMu i
SuU )HI tlO.UO, kUI DO luluuiM DI Im
Tit* ir(a« ■•»■■■ m ma, -m,
P*'>ralta of 9hla 1U»k««
I koulii |iub1Wh>4 dv
A DetnliiQtp Ottatone «r the eocfctT'i tflu of Portrahi oT DiMUM rf Ibl SU^ m4 iMk
IBFOBT, vin b* fimbti*! rnlli apon kpptiutlim.
$4 00
CI
(I
II
II
11
II
II
II
II
11
Reprint,
««
Philadelphia,
London,
Dublin,
New York,
London,
II
•
New Tork,
II
Now Orleans,
London,
Philadelphia,
Boston
10 00
AMERICAN & BRITISH PERIODICALS
BUPPLIXD BT
LINDSAY & BLAKISTON,
PHILADELPHIA.
Sn.l>8oriptioxi8 Payable In Ad.van.oe.
VA1CE& WHEM PUBLBHBD. MIOB
Per
TEARIiT.
The Pennsylvania JTotpital Reportt, .... Vols. 1 & 2, each,
The Phyneian'e Vieiting List, for 1871, prices redaced. See Catalogue.
Clinieal Society*8 Transaetionty ..... London,
Si, Andrew*8 Medical Oraduatee* Aeeodation Reporte^
The London Hoepitcd HtporUf London,
7%« Liverpool *<
SL Qeorge'a "
SL Bartholomew *.'
€hty*a " "
Obatetrieal Socieiy^a TVanatutionaf • • . •
Pathological " " ....
Medico- Chirurfficttl Society* a TVanaactionat .
The New Syiienham Society* a PubUcaiiona. 8 to 4 yol-
umes published annually, ......
JOTALF'TEABLT.
BraHh\oaite*a Retrospect of Medicine and Surgery^
Ranking* a Half- Yearly Abstract <* *«
QUARTERLY.
American Journal of the Medical Sdencea, .
British and Foreign Medico-Chirurgical Review^ .
The Dublin (Quarterly Journal of Medicine^ .
American Journal of Syphilography and Dermatology^
Journal of Anatomy and Physiology, $2.00 per Number,
Microscopical Journal^
The American Journal of Obstetrics , ....
Journal of Psychological Medicine^ . , • .
The New Orleans Journal of Medicine^
The Ophthalmic Hospital Reports^ ....
BI'MONTHLT.
T%e American Journal of Pharmacy^ .
MONTHLY.
Journal of the Qynmeological Soeietyt • . .
The London Lancet, . . . . . . . Reprint, .
The Pharmaceutical Journal j London,
The Medical and Surgical Journal, .... Edinburgh,
The Practitioner, Edited by F. £. Anstie, M. D., . . Reprint, .
Chemical Nevon, . . : New Tork,
The Medical Archtvea, .St. Louis,
The Richmond and Louisville Medical Journal, • . Louisyille,
The Chicago Medical Journal, ,
New York Medical Journal, New Tork,
SEMI'MONTHLY.
The Medical Times, Philadelphia,
The Medical Record, New York,
WEEKLY.
The London Lancet, London, •
« Medical Times and Oazette, <«
** British Medical Journal, ««
•' Medical and SmrgicfU MepofieTy . • • . Philadelphia,
** Medical and Surgical Journal^ .... Boston,
Any other Jonmala wlU be fanUshed to ordei;
. >
2 60
2 60
600
10 00
10 00
800
800
4 00
600
600
8 00
800
600
6 00
800
4 00
6 00
8 00
6 00
8 00
4 00
•
4 00
4 00
12 00
12 00
12 00
6 00
4tO
■ English Medical Books. Recent Importations. 1
K MANT OP THEM ON HAND IN QUANTITIES. ■
■ 8mt free by mail at t/ie priccit aunej-.d, oHrf fui-nialted to the TrvtU ■
^^ at a UbertU ditiwuiU. H
H BoELBitBO WbllV Complel. Trenlli. on Di.enK. of the Ej.. S...,..,i, J LOSD
^H Wklui' an LdBB, Bbart, aud Wesli Sight. 3d Eililion.
^H BiiATnt>aDi»Me>iLn<IInjurifl>Dni>« J>w>. Illiulnted,
^B HoL>iu-Surgiu>il£;uKni«f CbUdren. !d EdLligo,
^H GtOKKaow oa ChrdniD Broncbliii
^P BSALU' now tuWnrk thflMicroawpo. 400 [Uiutntiofis,
BitLI OD Kiduo; DItwai, Urinu; UepoiiK, As., Ao. 400 UluolratloDt, .
MEnrci5K.sMi)n..ni.Tnir.. «™
TuorMBiu'B UBclunu on Clinical Midicioi. Vol.. 1, S. and 3, a^],, .
ThkN«w Srni«a*ii BoBETr'B PoBLiUiTiusB, perivtujiim, .
TArwfl'. ?riiniijil8.«nd Pr*itlo« of Medial HuriHirudeDB^ .
Bealb on Dixued Germs. BO Ci.lorea Sngmvinit.. .
LKfla'aQuidiitotli«BiaiBiniitint,t.f (irino. 2d KJirlon. .
Mejiico Cmnirnoip*!. Bociktt'b TmssALTtcfs, Vol. 5S, fnr 1««fl.
Altbiui' MfldionratntrlDitf. 2d EdiLiun. Kni>ir|i:i!j kud IllDitrkliKl, .
BiBRUrDn Dropi]'. 3d Kdlilun. Gnluged sod IllDetrnlsd, .
CoLi.is on CiOMr nnd T«oiDr». IllnslriilBj, ....
Cooke DD Cancer; it^Altix, Ao. Culored IlIuatrfttioDi,
PANJCrt PreotiMl HjrgiBno. Sd Edition
^b Gm*VK-!i CIlDlcal LoDtarai b; Nul)g:ia. A Non Edillon, .
^H Dtr'lOlinical ITiiitorlcB oith ConinivbM, ....
^P B>JLLt-BPp>lapln<in:or, Lib, MmtH, Hind. Id Edition. 8 IIl<»trat>»Di,
^M ToTHBii un tbe Ear. A nsir Edition, bj tlinlon.
HOLHU' Sy.tein of Surgery. S »..l.„ 8».,. No* Biilloo, per ToL, .
LiR-i DiHKiM of tbe Vein, aod Ilu'murrhoid«i Tuuiort,
CiTLOirtPrinciplesof«flheilc.Molidnu
B*iit»BR«w»oii Ovurinn Drojiny. Hm . nluth, ....
a*iiL«f 1 Old Veei-UlilE NMaorioi. iilij.vu, ....
Hi80iiiWTTOiioHbBU»eof Kittuieof Sil.er, ....
WiBi-TnoH's Diotiona^' of Hftteria Mwiioa aod Tbenipratioii. OataTo,
^m Rnri'oi.n'* eyitom of Medtclns. Kew Kdltlnn, per Tslano,
^ lli.,Toll'»I«.clorB.onR-itMdPain. Tllk..lrn>c/!.
H FoWMK-S Manual of Cheminry. lOtb Ediiioa. Boriacd and Enlarged, .
^H LlTTi.a UR Sniaal WeaiiueBB and Corvnlurei, ....
H nonLnt-s Oiellon.ry of Medieal Tn-ma. Mih Edition. KoUrged,
B SAKniuuus-s Hand Book of the 8pb*>'gtdugr»pb,
H UonnlioDlrrifabiJil;, A«, leino., clolb,
H BiHGH en tbe U>e an Valoe of Oxygen. IBino., olotb, .
■ Vmam an ITlpritie Disorder!. 8<g.. olotb.
H &AKT on the Irritable Bla.1der: IteCnuui and CnntlTe Treatment, .
^H DBaUHtnr^ Manual of Iho Tarkl>fa Balh. llluitraud.
^H Qnr-a FerenEia Modleine. Sd Edition. Reriied and Enlarged, with Itlaeln
^B eAIRDIirannnOuul; itt HliCory, Caniei, and Cure,
^1 MnoaR DO Redent CiDcer.
^ B*«Br'» Loolorel on Monln] DiteaKei. 8vo., oTolb, .
eimnw of the Palhologica: Seriea in (he OiTord MnMnm,
Tatuh on PniHinB. Sd London EdlUon, .....
RoTLfl A llK«DL4icn'a Mnteria Medioa and Tberapeutiei. tth Edition,
^m Lnsnos (Ibsioirienl Suoioly's TmnaactioTii. Vol, 10,
^L Pol'aKB on tbe Eye. Illnilratod. Oetaro, eloth,
^B OAnrBBTiB on (be Uieruauupe. Foarth Kefiied Edition, .
H See Pertndiual Li«t of HoiplUl B*p«tt», TraniMtioni af Sofiietiei,
H pm- EasUab Hedlcal Bsoki not on band imported promptly 1o order at t
ON
ion
uid
e)o
1
F
1
>TBl
1
1
a^M
uo
T.OO
10.M
!-M
tit
t.W
Ti
«.1lB
«.»
«J}
R*«
t.M
(lOD
. s.:I
1.01
. t,«)
JJ«
1.H
iM
<-«
. 1.7]
4JM
Ml
t.>l
W»
B.a*
tM
«.U
. IJJ
in
Lit
>.)!
4.M
*;»
«.»
TIB
W.M
«-;s
LINDSAY AND BLAKISTON'S PUBLICATIONS.
Anatomical Plates.
X'B PHT8I0L0GICAL BIAOBAKS. Nine Plates in the set. Fignm ilz Aek taf )
Life-site; printed on one sheet 4x7 feet; beAutifolly colored*
Contanti.
No. 1.— 'The Skeleton and Ligaments.
3. — The Muscles, Joints, and Animal Me-
ohanios.
S. — The Viscera in Position ; the Stmotnre of
the Lungs.
4. — The Heart and Blood-ressels.
No. 5. — The Ljmphatios, or Absorbenti.
6. — The Digestive Organs.
7. — The Brain and Nerves.
8. — The Organs of the Senses.
9. — The Textures and Microscopic Stmo-
ture.
Ilandsomolj mounted on rollers. Price, • . . , . . $90.00
In sheets, .......••• 60.00
LECTURE DIA0RAM8 FOR IN8TRTTCTI0H IN PREGNANCY ANB MIDWIFERT. 20 Plates
of the largest imperial size, printed in colors. Drawn and Edited with Explanatory Notes by Dr«
B. S. Schultze, Professor of Midwifery at the University in Jena. Price, • . • $184M
BOUROERT k JACOB'S PLATES. Twenty in the set. Figures three feet long, beautifully eolored;
mounted on rollers.
Per set. Price, ....•..••• $60.00
Sold Srparatr, each, ......••• E.00
The following are the subjects and arrangements of the plates : — ^
Oiteology and Syndesmologj.
Plate I. Anterior Plane. Bight tide: The Dry Dunes. Le/tnde: The Bones clothed with their
ligaments.
Plate II. Posterior plane. The same arrangement.
Myology and Aponenrology.
Plate 111. Anterior plane. Hight tide: Superficial muscles. Leffidt: Superficial aponourosea.
Plate IV. Anterior plane. Right tide: Muscles of the second layer. Le/t tide: Muscles o( the
third layer.
Plato V. Posterior plane. Bight tide: Superficial muscles. Ze/l ti(£e .* Superficial aponenroNi.
Plate VI. Puflterior plane. Second and Third layer of muscles.
Piute VII. Lateral plane. Superficial and deep muscles. Muscles of the os hyoides.
Plate VIII. Diaphragm. Interior of the trunk, muscles of the lower jaw, of the tongue, of ilw
rlum palati, and of the pharynx.
Angiology.
Heart, lungtf arteriee, veintf and lymphatice. On the different JIguree are indicated the pointe at wJUek
eomprettion on the ligature of the vettelt it effected, and in regard to tke 9eine in particular, the jirojuf
pointt for performing venetection.
Plate IX. Interior of the trunk. Heart, lungs, and their envelopes. Large Tossels.
Plato X. Vessels of the thorax and abdomen, acygos vessels, cerebral and spinal venous ■inuMl.
Plate XI. Anterior plane. Sub^cutaneous vein, and deep vessels.
Plato XII. Posterior plane. Suiierficial veinii, and deep vessels.
Plato XIII. Lateral plane. Partial figures, internal maxillary and internal carotid TeMMdi, kOm
Plato XIV. Lymphatic vessels.
Nenrology.
Plate XV. Anterior plane. Encephalic nerves. Nerves of the extremities.
Plate XVI. PoHtcrior plane. Studies of the ganglions and their nerves. Studies of the fifth aM
seventh cerebral pairs.
Plato XVII. Brain, spinal marrow, and envelopes. Organs of the senses. Larynx
Bigeitive Apparatua.
Plate XVIII. Alimentary canal: stomach, intestines, chyl'.ferous vessels, peritoneum.
Plate XIX. Stomach, liver, pancreait, s}ilecn, kidneys, supra-renal capsules, bladder. Abdtfuiilal
vcnou« Hvstcm. Great sympathetic and pnuumo-gastric nerves.
Plate XX. Complete study of the perineum in both sexes. Male and female organs of reproina-
tion. Embryotomy.
FIEDLER'S ANATOMICAL PLATES, i in the set, mounted on rollers. Price, . . 9l6.f»#
LAMBEPT'f? ANAT02IICAL PLA.TE8. Figures three feet long, hnndsomcly eolf»rod, mounted aa
. AJ
'f<
.■• V
•i
!'•. r
1
1^ •. • • •
1
' ' '
i
t^ •
1
/■
*
4
.{
« .
J * ' » /
'•./
'• • f • 1 » f i ■
^ K / ' 1 • ■» ■ ■ .
• fil |,» .' • •
f ■ .
i ".
/ ■
.■:■./ ,
.'# . ' ..»
..'ft
'-/
''•.';•. • Afc". .-■ .7*
O'Uirr/*;/./, Ah/, ;,; ",;•;;•; r/;. ^/.•;/f/;rir;i/J 'j} UF.ir^AL B.-TE?. WITH IHE FBICDS
AM'n.Zi.ii. iJ.Hl ikJ.i; }jy MAIL U^yN A?ri.:cAi::>".
MEOKMCENTEB
STANFORD. CWF. 9"
il57 Paget, SlE J. 19487
PIS ledturee on surgical
_^
SH
j^H
ZSH
Z|^H
T, J<
^^^^^^1
_._.2l ./«
l^^^^^l
-~-2J •'^
1
„-0.
")
-